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SAN JOAUUIN Environmental Health Department <br /> COL)NIT Y <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility • Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> ff 7-1 <br /> . To be com leted b APPLICANT <br /> P- ._._.- — -- -- <br /> Business Name rTf T h �T rc, Plate# L �' <br /> Owner/Operator Name jj_,y ,ny p <br /> Business Mailing Address of ic AV&z,,-3 c. <br /> City -OCI(T StateG4 Zip SZt —Bus. Ph. ' <br /> r� Al A 1p o hereby state that the above information is current, true and correct to <br /> Vie best of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin Coun y F wronmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinucri i pen it h der roust notify the EFUD. Failure to notify this office may result in permit <br /> 4 <br /> revocation and penalties. <br /> Signature A—> <br /> - —_- '` " <br /> (�X <br /> 2_To be comleted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name_ FA# <br /> Address Bus. Phone <br /> City Zip --_OwnerlOperator <br /> Check all appropriate services provided: <br /> U( Wastewater disposal K 3-compartment sink IKElectrical hook-ups <br /> Solid waste disposal Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning Story; refrigerated food Potable water <br /> Store dry food/supplies .Overnight parking pal Vehicle wash <br /> l - hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall notify the FHD immediately. <br /> Signature--..----.—. _Date - . <br /> [ 3._To be completed the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checked services are available at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> REHS Signature ... Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 I F 209 464-0138 1 www.sjgov.orglehd <br /> 1 I� 2c�c�2.1.cp <br />