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S A N J O A Q U I N Environmental Health Department <br /> {. COUNTY <br /> ="�twoe, Crearne�s grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be com feted by APPLICANT <br /> Business Name Eve.\ L.ic. Plate# <br /> Owner/Operator Name 1o1., <br /> Business Mailing Address =r- Uvu• <br /> City .5 State 4-Zip 52\2 Bus. Ph�v 7_4L�aItA S� Aft. Ph. <br /> hereby state that the above information is current, true and correct to <br /> the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and p lties. <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name FA# <br /> Address 3y(l 1E N tYQC QA9- Bus. Phone QLpct-143;rR -Lt'l3 143 <br /> Ci Zip Owner/Operator Saxl(` <br /> Check all appropriate services provided. LS1)�CaA_ <br /> LA <br /> `%-Wastewater disposal 1�3-compartment sink Electrical hook-ups C) <br /> ® Solid waste disposal E-1 Food preparation Toilet and handwashing m Z <br /> Hot & Cold water for cleaning 0 Store refrigerated food Potable water t7 <br /> ZicO <br /> ® Store dry food/supplies Overnight parking El Vehicle wash Z — <br /> I, SathaM Sc��n� hereby state that the information I have provided is current, true a M m <br /> correct to the best of my knowledge, and meets the California Health &Safety Code requirements. If the food facie D ;U <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, M C m <br /> commissary owner shall notify the EHD immediately. 0 M n <br /> Signature Date C <br /> 3. To be completed by 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 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> W,2�0DDZ-1-1 <br />