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SAN JOAQUIN Environmental Health Department <br /> C 0 U N Y <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ,� Caterer <br /> Complete sections i and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> . To be completed by APPLICANT <br /> Business Name.A 4�A i/±,;� Lic. Plate# <br /> Owner/Operator Name r^�r�� C rat on n� Ir�.S �[i'� CA42j'►C c A <br /> Business Mailing Address C1 100 (4 /,,i LA 5 c'>'] � <br /> City j/ ,1.6o«_,� State_L&Zip Y � Bus. Ph. Alt. Ph. <br /> I, 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.Signature .1C--"e _� � I2 6n4,— _. Date_�� <br /> 2. To be completed by COMMISSARY OWNEWOPERATOR <br /> Commissary Name t't FA# <br /> Address � (/� ,-L. Bus. Phone <br /> City_ �T) Zip Owner/Operator ) L (� <br /> Check all appropriate services provided; 11 <br /> Wastewater disposal 10 3-compartment sink C! Electrical hook-ups <br /> Solid waste disposal 12 Food preparation Toilet and handwashing <br /> Hot& Cold water for cleaning P7 Store refrigerated food Potable water <br /> Store dry food/supplies ® Overnight parking ® Vehicle wash <br /> 1, 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 Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa rain 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 (www.sigov.org/chd <br />