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SQN:IOAQUIN Environmental Health Department <br />—COUNTY— <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. Tobe completed by APPLICANT <br />Business Name <br />Owner/Operator <br />Business Mailing <br />Plate # 1 M l� S to min <br />CityS0cX'(ArY1PX117S StatejZA_ZipU ?/Bus. Ph.61_14 W2- /il5q Alt. Ph.,1 Il al:�loO- S info L <br />I, V i r i Blow NQ" las hereby state that the above information is current, true and correct to <br />the best of my knowledg6 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 <br />�ann penalties. <br />Signature_yi NiA-0,4 - e&l _ C Datey5- / I:? /2 t <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />CommissaryName I t, ChCk FA# •0 <br />• s• • Bus. Phone 0114 3B2- -z4'15q <br />mu • • .0 • •. .. a •••; /,•♦ ' <br />Check all appropriate services provided: <br />Wastewater disposal E(3 -compartment sink 13 Electrical hook-ups <br />Solid waste disposal F <br />__�(.Food preparation l2f Toilet and handwashing <br />Hot & Cold water for cleaning i- SStore refrigerated food M' Potable water <br />Store dry food/supplies zovernight parking p Vehicle wash <br />I, Vi'r i d►aw Naeaf es , hereby state that the information I have provided is current, true and <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply with the cqnditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary oyner shall notify t* VHD immediatelyq <br />3/7-7/9 <br />1 3. To be completed by the ENV HEALTH iurisdiction outside of San Joaquin Co. I <br />The commissary is located in `- t_ , OM414b 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 staff of their operating permit changes. <br />REHS Signature 0_ L / 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 />