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SAN JOAQUIN Environmental Health Department <br /> COUNTY <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 /> Business Name(}r1yyc)f fl?Y`n &,Vl ci Lic. Plate# g\lusn 2. <br /> Owner/Operator Name Fzryl Itl'� (�`�l►�� <br /> Business Mailing Address <br /> City ��� State-CEZip gS2L4aBus. Pl� U(1) 2q q CM3 Alt. Ph. <br /> I, E r wi iN. 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 3 1 1"A k 22-A <br /> Commissary Name �Z FA# <br /> Address (-oZO Bus. Phone(ZC6 C <br /> City cclr� \ Zip CTR Z- C) Owner/Operator mo <br /> Check all appropriate services provided: <br /> Wastewater disposal 0,,3-compartment sink Electrical hook-ups <br /> Solid waste disposal 0 Food preparation Toilet and handwashing <br /> 0,Hot & Cold water for cleaning 0 Store refrigerated food Potable water <br /> 13 Store dry food/supplies 00vernight parking ,'!�Vehicle wash <br /> I,� Mc�cC;('l A �zkf(C/1 hereby state that the information I have provided is current, true and <br /> correct to the best of my nowledge, an�ets 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 not the EHD immediately. <br /> Signature Date <br /> T' <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 />