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SAN J O A Q U 1 N Environmental Health Department <br /> COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> ,omplete 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 /> 3usiness Name f A C c P7 Lic. Plate# <br /> owner/Operator Name L[ Rilm -SG/�I7�!✓,L, 41I 1) <br /> 3usiness Mailing Address < < �% /x, 16 k L R & C J <br /> ,ity �� State c1V Zip�,L.31 7 Bus. P�:�C r��z� -e��_ `f Alt. Ph. <br /> hereby state that the above information is current, true and correct to <br /> he 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 /> .ommissary is discontinuedrthe permit holder must notify the EHD. Failure to notify this office may result in permit <br /> evocation all p nalties• <br /> signature :/ Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> :ommissary Name q <br /> address 2� 7 G(�i1 f1 lel J Bus. PhoneC�� cr ^ <br /> ;ityS_FUc.KT ori' += Zip ��� c L Ownerioperator X7_ <br /> t{ 7 (KV6 <br /> ;heck all appropriate services provided: <br /> Wastewater disposal U�3-compartment sink ® Electrical hook-ups <br /> Solid waste disposal <br /> 13 Food preparation 0 Toilet and handwashing <br /> Pio <br /> Store dry food/plies II�Overnight parking t & Cold water for cleaning Store refrigerated food I! Potable water <br /> / C /Vehicle wash <br /> hereby state that the information I have provided is current, true and <br /> orrect to the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility <br /> perator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> ommissary ow) r shat notify the EHD immediately. <br /> �� <br /> ignature Date �('� ` " e� <br /> 3. To be corn leted b the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> he commissary is located in County. The above food facility meets the <br /> ommissary requirements in California Health & Safety Code. The above checked services are available at the <br /> bone commissary. Please notify EHD if the status of their operating permit changes. <br /> EHS Signature Date <br /> 868 E. Hazelton Avenue 1 Stockton, California 95205 J T 209 468-3420 1 F 209 464-0108 1 www.sjgov.org/ehd <br />