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C' \ <br /> ;` S A N ]O A Q U I N Environmental Health Department <br /> COUNTY <br /> '-itiKoa?`rr �,reotnPSc grca.v; frier= <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 /> 9. To be completed by APPLICANT <br /> Business Name ESTR6 DE L&Q 6L-�5, '6t 5 Q Lic. Plate# { vS � <br /> Owner/Operator Name �CQ <br /> Business Mailing Address <br /> City0fN StateZip-►�' Bus. Ph. ' \5!A' Alk. Ph. <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 h er must notify the EHD. Failure to notify this office may result in permit <br /> revoci" n d penalti s <br /> Signatur DateLow; <br /> 2. To a co leted b COMMISSARY OWNER/OPERATOR <br /> Commissary Name r' J�/ I' 41) FA# <br /> Address / Bus. Phone <br /> City Gl Zip Ownerloperator <br /> Check all appropriate services provided: <br /> Wastewater disposal Iul_-3-compartment sink Electrical hook-ups <br /> /Solid waste disposal 0 Food preparation IL_Toilet and handwashing <br /> Hot & Cold water for cleaning 13 Store refrigerated food Potable water <br /> 0 Store dry food/supplies Overnight parking Vehicle wash <br /> 1 `e r� rr , 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 tify the EHD i mediately. <br /> Signature Date �" r , <br /> 3. To be com leted b the EALTH "urisdiction outside of San Joa in 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.sigov.org/ehd <br /> ; �2S 00__�"Z S <br />