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SAN JOAQUIN Environmental Health Department <br />--COUNTY-- <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Complete sections 1 and 2. ff your commissary is located outside of San Joaquin County also complete section 3- <br />1. To be cornpteted by APPLICANT <br />Business Name � 4 v' je- Lic. Plate # "��5z <br />Owner/Operator Name (" GI r i S Pc iJ, h cfs, ter, <br />Business Mailinci Address <br />City U<<' State Zip Bus. PhZ(2��7% S 25-7- t. Ph. <br />I, G Lr, k 'Z , , 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 />12. To be completed by COMMISSARY OWNER/OPERATOR I <br />Check all appropriate services provided: - <br />XWastewaterdisposal ❑ 3 -compartment sink ❑ Electrical hook-ups <br />Solid waste disposal ❑ Food preparation ❑ Toilet and handwashing <br />❑ Hot & Cold water for cleaning ❑ Store refrigerated food MPotable water <br />❑ Store dry food/supplie,g ❑ Overnight parking ❑ Vehicle wash <br />I, ,51%N e2r6Qhgg�'lJ , 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 coVail, <br />the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary ownethe EHD immediately. <br />^ //i- —, <br />13. To be completed by the ENV HEALTH iurisdiction outside of San Joaquin Co. I <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 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />