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r SA N . J UAU U I N Environmental Health Department <br /> r� <br /> 4 <br /> C OUN i'4' <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 /> 1. To be completed by APPLICANT <br /> Business Name [. k s S CE Ff OT DA Plate# Clk <br /> Owner/Operator Name LiCPs y— /�INU ON - <br /> Business Mailing Address��y <br /> City State AZip'1537toBus. Ph IZ61 13 09-5&W. Ph. <br /> IDS 1Z , 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 pe Signature _ Date o g j 2 31 10 Z s <br /> 2. To be completed by COMMISSARY OWNEMPERATOR <br /> Commissary Name <br /> Address V N 10 N LF Bus. Phone 1� ' Co <br /> City S Zip Owner/Operator -11 C1 P-NVE T] rAbo <br /> Check all appropriate services provided: <br /> Wastewater disposal 3-compartment sink 0 Electrical hook-ups <br /> /[Solid waste disposal X Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning € a Store refrigerated food )U Potable water <br /> CZ Store dry food/supplies Overnight parking Vehicle wash <br /> I. A hereby state that the information I have provided is current, true and <br /> correct tot e be knowledge, and meets the California Health &Safety Code requirements. If the food facility <br /> operator fails to the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary I t the EHD immediately. <br /> Signature Date 23 2 <br /> 3. To b om leted by the ENV HEALTH jurisdiction outside of San Joa uin 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_orglehd <br />