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SAN JOAQUIN Environmental Health Department <br /> -:lJ N T Y--- -.. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility y Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To bcompleted To by APPLICANT <br /> Business Name L Pr �fi�/� 1-T 11 Lic.Plate fqlllX /00 0 <br /> Owner/Operator Name <br /> Bus' e s Mailin Address e <br /> C'ty ( T 03tatecfizip =b Bus. Ph 2 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 OWNERIOPERATOR <br /> Commissary Nam fili6pF h b <br /> Address Yl 1 Bus. Phone 2 <br /> City ( Zip(�Owner/Operator Va C) t� <br /> Che all appropriate services provided: <br /> Wastewater disposal Cr 3-compartment sink electrical hook-ups <br /> g'-s/olid waste disposal Food preparation EToilet and handwashing <br /> 0400t&Cold water for cleaning 0 St ra refrigerated food Q Potable water <br /> O Store dry food/supplies Ovemight parking ehicle wash <br /> 1, 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 toly with the conditions of this agreement, o if this agreement is m dified r cancelled, the <br /> commissary ow stify f HD' ediately. O <br /> Si nature A� Date <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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />