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v <br /> SANAMUiN Environmental Health Department <br /> < Greatness atvvvs <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 com leted by APPLICANT <br /> Business Name ' Lic.Plate <br /> Owner/Operator Name <br /> Business Mailing Address <br /> City Stat ry�Zip�—Bus. Ph., tb :ty Alt. Ph. <br /> I, ` 6� n , 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 mu notify the EHD. Failure to notify this office may result in permit <br /> revocation and penaltie .__ <br /> Signature` / Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary?Name ", <br /> C. FAQ# <br /> Address �t �r G j �. Bus. Phone P42 �{c <br /> N <br /> City <br /> Zi S wner/0 erator <br /> Check all appropriate services provided: <br /> ID Wastewater disposal C 3-compartment sink M Electrical hook-ups <br /> M Solid waste disposal U Food preparation It Toilet and handwashing <br /> M Hot& Cold water for cleaning a Store refrigerated food 0 Potable water <br /> E re dry food/s pplies El Overnight parking It Vehicle wash <br /> I, " V1CZti►. hereby state that the information I have provided is current,true and <br /> correct tojp6r <br /> my knowledge, meets the California Health&Safety Code requirements. If the food facility <br /> operatorply with the co itions of this agreement, or if this agreement is modified or cancelled, the <br /> commisshat!notify t HD immediately. <br /> Zzt�Lre _ DateSignaturzt.J -- <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 />