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f,2osy �,54,0/�3 <br /> SHAUN Environmental Health Department <br /> COUNTY <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 /> 1. To be completed by APPLICANT <br /> Business Name It Lic. Plate# 1 &UACJS1 <br /> Owner/Operator Name <br /> Business Mailing Address I <br /> Cit <br /> y L,d lQ- CK State Zip c1SS ciBus. Ph. L yl `(t OG 1ti Alt. Ph. <br /> t , hereby state that the above information is current,true and correct to <br /> the best of my knowle ge 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. <br /> Signature '�,T; d Q.? Date L - 4 f- L Z <br /> 1 <br /> 2. To be completqd.by COMMISSARY OWNER/OPERATOR <br /> Commissary Name L FA# a� 4 93 <br /> Address—, - 2 0,l f}e- 4 nJ R4 Bus. Phone .209 - 7` 7 M <br /> city - <br /> -T Zip 7�0Owner/Operator v t <br /> Check all appropriate services provided: <br /> Wastewater disposal ❑ 3-compartment sink , Electrical hook-ups <br /> p� Solid waste disposal ❑ Food preparation 60/Toilet and handwashing <br /> ❑ Hot& Cold water for cleaning ❑ Store refrigerated food [P(Potable water <br /> [3 Store dry food/supplies Overnight parking E Vehicle wash <br /> I. S4C V0--- « 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 comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary own hall no ifQ1 a EHD immediately. <br /> Signature Date 7 Z <br /> 3. To b com leted b the ENV HEALTH jurisdiction 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 cinnv nmlphd S <br />