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L <br />SAN JOAQUIN <br />--C0UNT`r-- <br />Environmental Healthepartti int <br />COMMISSARY AGREEMENT <br />Mobile Food Facility.,. Caterer 11 <br />Complete 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 />plJ <br />Business Name c��y f A5: �/J 0W Lic. Plate # <br />Owner/Operator Name l r✓�il��.c�uf t/i�, <br />B usiness Mailing Address C5 P <br />I,� lAf/ 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, thetpermit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and 'es. <br />I <br />Sionature (C 61/!r)atP <br />12_ To be completed by COMMISSARY OWNER/OPERATOR I' <br />all appropriate services provided: <br />) Solid waste disposal <br />3 -compartment sink <br />W_ Food preparation <br />Toilet and handwashirig <br />I41 -lot & Cold water for cleaning tore refrigerated food jy<l Potable water <br />Store dry food/supppliies__ :tt-Overnight parking 0- Vehicle wash <br />I. i wi � &4 1% AJ , 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 conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary gywf er shall notify .tf a EHD imm ely. % <br />c;....�n,.e "?� n n., ..,. o .I ��. / <br />13. To be completed by the ENV HEALTH iurisdiction outside of San Joaquin Co. 1 <br />The commissary is located <br />cq'mmissary requirements in <br />above commissary.�[/P`I�vase <br />REHS Sicnature /6 1%. <br />in <br />California H alth & Safety Code. <br />notify EHD f[he status ofjhor ope <br />County. The above food facility meets the <br />above checked services are available at the <br />permit changes. <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 20146'8-3420 1 F 209 464-0138 1 wvN/.sjgov.orglehd' <br />