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SAN 10AQU I N Environmental Health Department <br />--COUNTY--- <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 %7 (C� S �lr d - ct �U - Lic. Plate # A J b <br />Owner/Operator Name I Z <br />Business Mailing Address_ " U //,b 112�^P/hryC,( J% / <br />City -r StateZip 2�,Bus. Ph. 7J 7r - S Z 5 7 Alt. Ph. Zd5 6 677- �% /"S- <br />I, ✓/ l CZi r7GZV7Zi , 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 penalties. L <br />Chk all appropriate services provided: <br />Wastewater disposal ❑ 3 -compartment sink ❑ Electrical hook-ups <br />❑ Solid waste disposal ❑ Food preparation ;Zotab <br />nd handwashing <br />❑ Hot & Cold water for cleaning ❑ Store refrigerated food water <br />❑ Store dry food/supp/Jr_es ❑ Overnight parking ❑ Vehicle wash <br />'6—1, S / - o�M�6 , hereby 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 co y yri tif conditions of this agreement, or this agreement is modified or cancelled, the <br />commissary o er sha in the EHD immediately. �� Z Z— <br />i <br />�Signatur Date <br />3. Tobe completed by the ENV HEALTHjurisdiction 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 www.sjgov.org/ehd <br />