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SAN _10AQUIN Environmental Health Department <br /> COUNTY — <br /> Greatness grows here. <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 �j/ <br /> Business Name �i� 0 1,/, a�l(2f�G1 Lic. Plate# I D ZS �S <br /> Owner/Operator Name X' Sites &�l-reZ' <br /> Business Mailing Address 7/b7 E t /h;le- ( OJ <br /> City g/jizk'r1//t State CPZip- <br /> Z12- Bus. Ph. Z0y-ZyY-S;7?2 Alt. Ph. <br /> I, JPjw home Z/ , 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. ? <br /> Signature <br /> Date__T /-ZJ <br /> 2�oDe com leted b COMMISSARY OWNER/OPERATOR <br /> CoNam a FA# <br /> Address- Bus.Bus. Phone afOf� <br /> City ¢ lrt� Zip T$'t7� Owner/Operator',P& (��0� �D <br /> Check all appropriate services provided: <br /> 0 Wastewater disposal 6 3-compartment sink M Electrical hook-ups <br /> It Solid waste disposal 13 Food preparation 0 Toilet and handwashing <br /> E3 Hot & Cold water for cleaning 13 Store refrigerated food Ell Potable water <br /> O/&t�pre dry f <br /> [ood/supplies V Overnight parking 6! Vehicle wash <br /> I,l ONk/t /e/x%dkZ 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 co ions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary er shall notify t HD immediately. <br /> Signature ate 3 <br /> 3. To be completed by 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.sjgov.org/ehd <br />