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SANAMUIN Environmental Health Department <br /> -------C0uNTY- - <br /> 4 . Greatness vtows hese <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 '`+ Lic.Plate#T6 IC� l <br /> Owner/Operator Name <br /> Business Mailing Address j`i <br /> CitState(.//rl Zip �' S<3( Bus. Ph.;.)P-f- /- I%l C/7 Alt. Ph. <br /> c,. 1-9,n 7-c.l 1-7 , 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 per it holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and alties. <br /> Signature Date "�`D��Y <br /> 2. To be com leted b _CO MISSARY OWNER/OPERATOR <br /> Commissary Name,-4 ''�I�l t_�.i�t.Y -'c FA# <br /> Address G�� �" ' Sus. Phone ,�G'�j <br /> . � i <br /> Cit - Zip �fU� wner/Operator <br /> Check all appropriate services provided: <br /> di Wastewater disposal 3-compartment sink Electrical hook-ups <br /> Solid waste disposal Food preparation Toilet and handwashing <br /> Ek Hot& Cold water for cleaning E3 Store refrigerated food t9 Potable water <br /> 0 S re dry food/spiles 1A Overnight parking Lj 'Vehicle wash <br /> I, _, hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,an d;meets the California Health&Safety Code requirements. If the food facility <br /> operator fail o omply with the cof�itions of this agreement, or if this agreement is modified or cancelled, the <br /> commissa off! er shall notify the-fl-ID immediately. 14- <br /> '! �tic�-z,__ _ Date /f/ <br /> Signature L 7i-'Z 1� .v`� _,Z,2 <br /> r <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 952051 T 209 468-3420 1 F 209 464--0438 1 www.sjgov.orglehd <br />