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SAN JOAQUIN Environmental Health Department <br />_OUNTY <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3 <br />11. To be completed by APPLICANT <br />Business Name6- Lic. Plate # <br />Owner/Operator Name <br />Business Mailing Address <br />ereby state that the above information is current, true and correct to <br />the est of 64yf 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 disconti the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocations es. <br />Q;-. (f n.t : <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name O J(l i )C e4J 00n�nV 5Say'� FA# <br />Address q00 'AC); to 2. C> Bus. Phone u,)5, - 51)- 6 <br />Check all appropriate services provided: <br />El -Wastewater disposal U -3 -compartment sink t -Electrical hook-ups <br />[3 -Solid waste disposal C -Food preparation tf Toilet and handwashing <br />13 -Hot & Cold water for cleaning dStore refrigerated food C�Potable water <br />i'Store dry food/supplies cKovemight parking C[�/ehicle wash <br />I, ; hereby state that the information I have provided is current, true and <br />correct to the best of my kno ledge, 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 />1 3. To be completed by the ENV HEALTH iurisdiction outside of San Joaquin Co. <br />The commissary is located in S6n !-ronci -5c c) 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 />S 01 a-71 22 <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 />