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SO- <br />SAN __ OAQU IN Environmental Health Department <br />COUNTY-- <br />Greotness grows here. <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 ( rY11C.1-1oawh Lic.Plate # QL Cg <br />Owr <br />Busi <br />City. <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 discontinuesltijp.germit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and <br />_Ia-- <br />Commissary Name <br />Address LZfi S <br />La -c& Y.or ^/y 5± Bus. Phone 6Wd 2 -2'V 4?X, <br />City LO P Zip 157-7d Owner/Operator <br />Check all appropriate services provided: <br />®'3 -compartment sink <br />®Wastewater disposal <br />l3�'�Electrical hook-ups <br />M"Solid waste disposal d� Food preparation C�'Toilet and handwashing <br />Ig" H%, & Cold water for cleaning 1 /tore refrigerated food Q Potable water <br />® Store dry food/supplies ta" Overnight parking Vehicle wash <br />I, z-Gher`S3 z 11' Z� lhereby 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 owner shall notify the EHD immediately. <br />Sig <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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />