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SAN,JOAQUIN 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 />Business Name <br />Owner/Operator Name <br />L� C <br />Plate # 1–(SN s i�3 <br />Business Mailing Address la'L lP y C <br />City 0,A-4f6L-a' State_C Zip ci 3 (Bus. Ph. %C�i��5 C�(c / Alt. Ph. <br />I, J�ft Lti o L 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 Denakies. — <br />2. To be completqdby COMMISSARY OWNER/OPERATOR <br />Commissary Name_ L <br />city _LF! i4� Zi <br />Check all appropriate services <br />R(Wastewater disposal <br />ImJ Solid waste disposal <br />i L <br />Phone •- c <br />❑ 3 -compartment sink Electrical hook-ups <br />❑ Food preparation Toilet and handwashing <br />❑ Hot & Cold water for cleaning 13 Store refrigerated food [Potable water <br />13Storedry food/supplies ff"/Ovemight parking Lf7 Vehicle wash <br />e�IfL%>vyL hereby state that the information I have provided is current, true and <br />correct to the best of my knowledgefand 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 ownwshall notal ie EHD immediately. I i <br />L3. To bb/completed by the ENV HEALTH iurisdictinn rndsidp of Ran .Inanidn Rn <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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />J <br />