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25X-41s <br /> SQ N �J O A Q U I N Environmental Health Department <br /> '---COUNTY----- <br /> �'rIP55 '�1�C75v 7erR, <br /> COMMISSARY AGREEMENT } <br /> Mobile Food Facility e 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 '\ e_ gipp,', �q— .,0 <br /> Lic. Plate# <br /> Owner/Operator Name Cj-_ C v `� S��— <br /> Business Mailing Address �D� CI'� ✓L r� <br /> City �tState�Zip Bus. �7�� 1 $ 'f Y It. Ph. <br /> IA (A I C/— , 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 ik <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 penaltie . <br /> Signatur <br /> 2. To be comp;Iletlecdl b COWNSSARY OWNER/OPERATOR <br /> Commissary Name O FA# <br /> Address :U t <br /> Bus. Phone <br /> City_ 4a LI _ Zip C OwnerlOperator <br /> Check all appropriate services provided: <br /> Wastewater disposal 1(3-compartment sink ❑ Electrical hook-ups <br /> Solid waste disposal ❑ Food preparation VToilet and handwashing <br /> Hot& Cold water for cleaning ❑ Store refrigerated food k'Potable water <br /> Store dry foodlsu plies ❑ Overnight parking Or Vehicle wash <br /> I, , hereby state that the information I have provided is current,true and <br /> correct to the est of my knowled 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 ediately. <br /> Signature Date r <br /> 3. To be com feted b the EALTH 'urisdiction•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.sigov.org/ehd <br />