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SAN OAQ U I N Environmental Health Department <br /> J <br /> r 7 <br /> Greotness grow, <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete sections 9 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 ,I(\j Lic. Plate# u ,^/ U l� yS �-7 <br /> Owner/Operator Name ?W S1 t�X111 <br /> Business Mailing Address <br /> City -1 StateC_,A Zip rs Bus. Ph.2 o9 3,, 'J-9701t. Ph. <br /> I, 1 ftkAiviz 'fr OT. <-'-N Pf , 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 Date DS ' <br /> 2. To be <br /> comp leted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name -r '.S-d/x CL FA# <br /> Address S (.�!' Bus. Phone / 9 <br /> City LL�� i Zip + C_ Owner/Operator / 1�1 41"'t, <br /> Check all appropriate services provided- <br /> Wastewater disposal [3 3-compartment sink ® Electrical hook-ups <br /> $� Solid waste disposal [3 Food preparation ff Toilet and handwashing <br /> Hot & Cold water for cleaning 0 Store refrigerated foodPotable water <br /> ® Store dry foo d/supp iiees Of Overnight parking Vehicle wash <br /> 1, /A `� �� , hereby state that the information I have provided is current,true and <br /> correct to the best of my know) ge,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 owners II notiN the E ediately. L <br /> Signature Date <br /> 3. To be completed by the V 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 /> P01- 0 S' Slo <br />