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" F S A N,tJ OA Q U I N Environmental Health Department <br /> COUNTY <br /> Gre(Nness grows herr- <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 Q Lic. Plate# <br /> Owner/Operator Name <br /> i <br /> Business M ilinngrAddress �� �� �� �V'i E'�� <br /> City �- [b") -� StateC") Zip C6U23Bus. P&O — �` Alt. Ph. <br /> hereby state that the above information is current, true and correct to <br /> the best of my knowledge and agree to 6tilize 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 ust notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature /� Date ` / C�- r <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name �� t 7 CU►� TA# 9P`�`JU� <br /> Address d Bus. Phone ' 3i5 — <br /> Cit Owner/Operator G� N <br /> Check all appropriate services provided: <br /> p Wastewater disposal 0 3-compartment sink D Electrical hook-ups <br /> E] Solid waste disposal 0 Food preparation 0 Toilet and handwashing <br /> CI Hot & Cold water for cleaning C) Store refrigerated food 13 Potable water <br /> ore ry food/su plie © Overnight parking 0 Vehicle wash <br /> hereby state that the information I have provided is current, true and <br /> correct to the best of m�E,cnowledge, and meets the California Health &Safety Code requirements. If the food facility <br /> operator fail to com ly h the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> ,ecner s all n the EHD immediately. <br /> SiZure Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in (�0'tc4y 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 J 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 />