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_ i ��:=,i S- j! iii .ri f� �. o-^r, r� ' •f. <br /> --COU ISI T Y-- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o 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 Lic. Plate# r'1 U C 6T <br /> Owner/Operator Name o'r ��Ze <br /> Business Mailing Address 3,b1°t W 1JVIRtC)n Lave. Yst <br /> City S��k?3r\ State C&Zip •Zl Bus. Ph. 6 Alt. Ph. <br /> I, C�Gr Cw .Pn _ hereby state that the above information is current,true and correct to <br /> the best ofJmy 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 Ities. <br /> Signature �' Date �2c7 <br /> 2. To be completed by COMMISSARYO�WNER/OPERATOR <br /> Commissary Name ' 1 FA# <br /> Address / I Ls � Bus. Phone <br /> City ��id!✓ Zip— Owner/Operator L <br /> Check all appropriate services provided: <br /> : ??Wastewater disposal C 3-compartment sink �C Electrical hook-ups <br /> WSolid waste disposal Food preparation Toilet and handwashing <br /> Hot &Cold water for cleaning T Store refrigerated foody,' Potable water <br /> h Store dry foo <br /> d/ upplies Overnight parking Vehicle wash <br /> hereby state that the information I have provided is current,true and <br /> correct to the best of my know)1469e, and meets the California Health &Safety Code requirements. If the food.facility <br /> operator fails to comply witff the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shallthe HDI tely. <br /> Signature A 0 1 Date ��'0 <br /> 3. To be completed by the 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 95205 1 T 209 468-3420 1 F 209 464-0138 1 wvvw.sjgov.org/ehd <br />