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SAN JOAQUIN Environmental Health DepaKment <br /> _c,uv; <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 p' f <br /> Business Name L Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address <br /> city_s-�f&Rh Stateck by Bus. Ph. m)��I kH 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 quin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary i di tlnued, unit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation a e ie <br /> Signature Date `1 2 22 <br /> Z. To b com b COMMISSARY OWNER/OPERATOR <br /> T <br /> Commissary Name i FA# <br /> Address S Sus. Phone <br /> CityYr%T) 7ip��LOwner/Operator} L 1 4 I �1f4 <br /> Check all appropriate services provided: <br /> ;i Wastewater disposal M 3-compartment sink a Electrical hook-ups <br /> 14 Solid waste disposal M Food preparation Toilet and handwashing <br /> V Hot&Cold water for cleaning W1'Store refrigerated food Potable water <br /> I Store der food/supp'Jfifies f - � Overnight parking ® Vehicle wash <br /> I, / ©?u L 1\9 4/J ��0 ,hereby state that the information I have provided is current, true and <br /> correct to he ebeb st of my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the con"ons of this agreement, or if this agreement is modified or cancelled, the <br /> commissary own r shat N tt9y the E immedi ly. <br /> Signature Date 7 ` - <br /> 3. <br /> _10b ppfflpI*4by the ENV_HEALTH 'urisdiction outstde of San Joa uin 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 vrvAv.sjgov.org/ehd <br />