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SAN JOAQUIN <br />----COUNTY- - <br />Environmental 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 />7. To be completed by APPLICANT <br />Business Name C L L E7N 1 E�,) At -Z l0 <br />Owner/Operator Name So fQt <br />Business Mailing Address2 q S- M O N IZ06 ST <br />Lic. Plate # tq 054 Z 1 <br />City S_P&M N State C -N Zip C1520CD Bus. Ph(_201,_)51Q1- Llbc(5 Alt. Ph. <br />I, <br />SOCCAC .dyMy Y C--' hereby state that the above information is current, true and correct to <br />the best o 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 penalties. <br />i <br />Signature Date (Q . Zq - 2020 <br />12. To be completed by COMMISSARY OWNER/OPERATOR 1 <br />Commissary Nam ( ` I <br />Add res Bus. Phone <br />Cit Hbn zip ��0 Owner/Operator <br />Check all appropriate services provided: <br />El"Wtewater disposal -compartment sink G Electrical hook-ups <br />Solid waste disposal Food preparation Toilet and handwashing <br />Zr-Hot & Cold water for cleaning 0---S <br />igerated food B Pota a water <br />St red fo /su liesqanmee <br />arkin ehicle wash <br />T� ry PPparking <br />I, , hereby state that the information I have provided is current, true and <br />conr c o he bes my knowledge,s the California Health & Safety Code requirements. If the food facility <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissaty kwner shell notify the EHD inyrWdiately. <br />Signature <br />al <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 />