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SAN IOAQUIN Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility .r 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 comj�pleted by APPLICANT <br /> Business Name 3T)C,S iI )tr <br /> P yln Lic.Plate# <br /> Owner/Operator Name <br /> Business Maili g Address <br /> Cit y�State ' -zip 3 Bus. Ph 2 Alt. Ph?pq 2aS3121 <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 oofttfi-ce/may resu t in Trmit <br /> revocationaqd perr�It� f�d� <br /> Signature `\`(y/ Date <br /> 12. ib bkCSSMY 0MOUPPERATOR <br /> Commissary Nam �) <br /> Address t1 l G Bus. Phone 2 <br /> City (, ZipOwner/Operator VR d G <br /> Wk all appropriate services provided: <br /> astewater disposal 1�2'�3-compartment sink F�lectrical hook-ups <br /> 0 slid waste disposal R Food preparation B`Toilet and handwashing <br /> Ca riot& Cold water for cleaning ❑ St re refrigerated food EX-Potable water <br /> Store dry food/supplies Ovemight parking ❑1/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 top&9ly with the conditions of this agreement, of if this agreement is mo fled o cancelled, the <br /> commissary ow r sh otify h HD' ediately. <br /> Signature Date J <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 95205 1 T 209 468-3420 1 F 209 464-0138 I www.sigov.orglehd <br />