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• <br />,5) <br />; CO AL,/ <br />SAN)JOAQUIN <br />COUNTY <br />Environmental Health Department <br />de. , <br />Greatness <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 by APPLICANT <br />Owner/Operator Name 1-1-Pr O\ 2_ <br />Business Name 1-k6 coS <br />Business Mailing Address \-1 \C‘ <br />J k , hereby state that the above information is current, true and correct to <br />StateWZiP-).)ai-) Bus. Ph. 20 <br />h\oiA <br />- \\3 Alt. Ph-1) 1\703i On <br />the best of my kno edge and agre to utilize my approved commissary in accordance with California Health & <br />Safety Code, and n Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br />commissa is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocatio an eralties. <br />Lic. Plate # <br />Signatur Date p\2_ <br />2. To be completed <br />Commissary Name I <br />SARY OWNER/OPERATOR <br />AdCQ- <br />B s. Phone <br />y \\V Pr\ <br />Address <br />Cit <br />Check all appropriate services prided: <br />\121 Solid waste disposal Food preparation <br />\Q Wastewater disposal ,1141 3-compartment sink <br />\I:1 Hot & Cold water for cleaning 0 Store refrigerated food <br /> <br />NO Store dry food/su plies Overnight parking <br />I, -Ph 1,-\ , hereby state that the information I have provided is current, true and <br />correct to th 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 />Signature Date <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 />RENS Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />Zip Owner/Operator <br />Electrical hook-ups <br />Toilet and handwashing <br />CI Potable water <br />Vehicle wash