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SAN JOAQUIN Environmental Health Department <br /> COUNTY <br /> Grectness <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility a 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 1 e (\W C Z CC)- Lic. Plate# <br /> Owner/Operator Name Z U\WI b GUl`i/t <br /> Business Mailing Address <br /> City State zip Bus. Ph. o 9— 21 679t <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. <br /> Signature Date <br /> 2. To be Completed by COMMISSARrY�OWNER/OPERATOR <br /> Commissary Name V FA# <br /> Address us. Phone <br /> City �LV(L(-y Zip G Owner/Operator <br /> Check all appropriate services provided: <br /> p Wastewater disposal © 3-compartment sink ❑ Electrical hook-ups <br /> p Solid waste disposal M Food preparation 0 Toilet and handwashing <br /> 13 Hot & Cold water for cleaning 0 S ore refrigerated food 0 Potable water <br /> Ca Store dry food/supplies Overnight parking 0 Vehicle wash <br /> I, , 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 o r shall notify the�EH/D' immediately. <br /> Signature C/ Date /a/ Z2Z 2 <br /> 3. 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 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br />