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SAN JOAQUIN <br /> <br />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 Lic. Plate # <br />Owner/Operator Name <br />Business Mailing Address <br />City <br /> <br />State Zip Bus. Ph. <br /> <br />Alt. Ph. <br /> <br />, 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 <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Cornmissary Name SAv-bc\cA-o C-c; -\<- \ A# <br />Address Ca.-1 Bus. Phone 6c--) - 'S S <br />City c--) c„-\ Zip CIS 2._ 2._ Owner/Operator c‘a.. --2 )C,iNC A C <br />Check all appropriate services provided: <br />cd Wastewater disposal 3-compartment sink Er Electrical hook-ups <br />Or Solid waste disposal //Food preparation 2' Toilet and handwashing <br />ig Hot & Cold water for cleaning ,Store refrigerated food lir Potable water <br />Er Store dry food/supplies --Overnight-parking ED—Vehicle-wash <br />, 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 />Signature <br />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 Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-34201 F 209 464-0138 I vvww.sjgov.org/ehd <br />Date - LI