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a DAWN Environmental Health Department <br /> - -C O U N T Y----- <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_ t 1 �� Lic. Plate# t4 I LI 8 7(o <br /> Owner/Operator Name \1-�C-�-Oc <br /> Business Mailing Address 1'Lal .y <br /> StateC\ Zip 0IS'LW Bus, Ph. Alt. Ph. <br /> I, 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 penalties. <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name L `�iM�S �C-� Z-�£ �Ca FA# <br /> Address loZO Bus. Phone Zo ZZq-- 6 7;3q <br /> City Loci\ Zip 9S 2 Lt0 Owner/Operator PM Q,(N6Cn C)CAno_01 <br /> Check all appropriate services provided- <br /> Wastewater disposal 3-compartment sink E€ectrical hook-ups <br /> Solid waste disposal - Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning Store refrigerated food X Potable water <br /> `iX Store dry food/supplies F,- Overnight parking N Vehicle wash <br /> hereby state that the information I have provided is current, true and <br /> correct to the est of my knowledge, and meets 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 /> commissary owner shall notify the EHD immediately. <br /> Signature_�� i i—+ 2-G�, Date O` <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 /> REBS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, Cafifornia 95205 1 T 209 468-3426 1 F 209 464-0138 1 www.sjgov.orglehd <br />