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j A N J Q G Q u I N FnVrironmentaf Health Department <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/ SU(, nfX1 r,4A/ t�D/0 Cd Lic. Plate# 7 V6eSV 90 <br /> Owner/Operator Name AL_ ,D 'D. Ct��Jfi/�lX� /oCn <br /> Business Mailing Ad/dress i <br /> StateeAZip FS 20Bus. Ph.ZIC)Q._ 2�10 ?? Alt. 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 Ities. <br /> SignatDate <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name i F kr FA# �— <br /> Address / Bus__Phone <br /> City ( ' Zip Owner/Operator W GGA 91' r <br /> Check all appropriate services provided: <br /> 9,4-Wastewater disposal 0 3-compartment sink I?( Electrical hook-ups <br /> Solid waste disposal 0 Food preparation �,(Toilet and handwashing <br /> G Hot & Cold Water for cleaning 7 Store refrigerated food IK Potable water <br /> MJ Store d food uppl VC Overnight parking l" Vehicle wash <br /> I, hereby state that the information I have provided is current, true and <br /> correct to he best of my know! e nd meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with on itions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner s' II noti the mmediately. <br /> Signature Date <br /> 3. To be completed b NV 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 'i 209 468-34201 F 209 464-0'138 1 �, ,w.sjgov.org/ehd <br />