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SAN 10AQUIN Environmental Health Department <br /> --COU NTY---- <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility * 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 com let6d'bv APPLICANT <br /> Business Name Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address <br /> City "r StateCkZip Bus. Ph. Alt. Ph. <br /> I, , 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. T <br /> Signature 3S' Date <br /> 2. To be completed b `COMMISSARY OWNER/OPERATOR <br /> Commissary Name Xa , FA# <br /> Address w D C�7 Bus. Phone <br /> City Zip 2!56;b3 Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal 0� 3-compartment sink 111 Electrical hook-ups <br /> Lt Solid waste disposal E3 Food preparation lb Toilet and handwashing <br /> 6 Hot & Cold water for cleaning O Store refrigerated food 6 Potable water <br /> © rtrY food�SUPPIies Overnight parking 16 Vehicle wash <br /> V%�- �Pd�llC z 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 owner shall notify the EHD immediately. <br /> zYa Date <br /> - /7 <br /> Signature z <br /> 3. To be,com` WWd``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.sjgov.org/ehd <br />