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SAN JOAQUIN <br />COUNTY <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility • 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 completed by APPLICANT <br />Business Name 6"1����uS<S �1�� Lic.Plate# Li�'Z3lU <br />Owner/Operator N <br />Business Mailing f <br />City.54ex K' —zIA Stat�Zip Bus. Ph(89J �26 ­9<_�V 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-cenaltiese I1 - <br />2. To be'completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name �Isz FA <br />Address -(07,0 eao; Bus. Phon C ZZLA 3344 <br />city LO& Zip gjS2K© Owner/Operator(G <br />Check all appropriate services provided: <br />'0 Wastewater disposal W 3 -compartment sink trElectrical hook-ups <br />It Solid waste disposal O Food preparation 8 Toilet and handwashing <br />�a Hot & Cold water for cleaning Al Store refrigerated food K Potable water <br />O'Store dry food/supplies 0 Overnight parking 1LVehicle wash <br />1, l'f1MiV\L`4,CC). A7.A-e C -CA _'hereby state that the information I have provided is current, true and <br />correct to the best of y knowledge, and meets t'he 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 owner shall notify, �e��HD immediately. <br />Signature //�/�/%/G��Z?`'/i,��/✓� Date Qq G% /z Z <br />1.3. To be coASleted by the ENV HEALTH jurisdiction 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 209 468-3420 1 F 209 464-0138 1 www,sjgov.org/ehd <br />