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SAN 10 A Q U I N Environmental Health Department <br /> LL?UN 1 Y <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 completed b Ay PPLICA,..,,N(rT <br /> Business Name ( Lic. Plate# 1p73�0 l� <br /> Owner/Operator Name_f S�, *�4y"b <br /> (itVlBusiness Mailing Address I/4'1 �A10r� <br /> City 1� State_aZip 1S377 Bus. Ph. ZUCI �7" Alt. Ph. <br /> I, hereby state that the above information is current,true and correct to <br /> the best of my know edge 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 /> I revocation and pe It* . <br /> Signature "`� ' Date <br /> 12. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name ,,;r., a FA# <br /> Address-3i1' ? Bus. Phone 2 on O 3 L_ SiI� � <br /> City_ Zip caner/Operator <br /> Check all appropnat' a services provided. <br /> p Wastewater disposal ❑ 3-compartment sink ❑ Electrical hook-ups <br /> Q Solid waste disposal ❑ Food preparation ❑ Toilet and handwashing <br /> C Hot & Cold water for cleaning ❑ Store refrigerated food M Potable water <br /> ❑ Store dry food/supplies Overnight parking ❑ Vehicle wash <br /> I, ,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 CoJshlI <br /> with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner notify the EHD immediately. <br /> Signature � Date I7 S 10 <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 Dale <br /> 1868 E Hazelton Avenue I Stockton,California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br />