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S A N J O A Q U IN Environmental Health Department COUNTY COMMISSARY AGREEMENT Mobile Food Facility o Caterer Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. 1. To be completed by APPLICANT Business Name Lic. Plate# Owner/Operator Name SGo.4.,7-1^,^/ n„v.i� C7-j--1 Business Mailing Address PC2 AS2 Y 6<1 3 Z 5 Z City_ �U G��r�� State Gd-Zip ��Bus. Ph. , - -Z , c> a'Alt. Ph. zo _ c rgS_ hereby state that the above information is current,true and correct to the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & Safety Code, and San Joaquin Co Environmental Health Department (EHD) requirements. if the use of the commissary is discontinued, the pemli holder must notify the EHD. Failure to notify this office may result in permit revocation andperialties. Signature �� !�\ Date_ Z!� 2. To be com le ed by COMMISSARY OWNER/OPERATOR ;n Commissary Name FA# Address 3 Bus. Phone aC' 3 34 - 2$ 3 City Zips{ Owner/Operator Check all appropriate services provided: 'Wastewater disposal 2"3-compartment sink ErElectrical hook-ups EJ�Solid waste disposal ❑ Food preparation G"Toilet and handwashing 1 Hot& Cold water for cleaning ❑ .Store refrigerated food EY'Potable water ❑ Store dry foodlsupplies// B"Ovemight parking l�Vehicle wash 1, 4&1- YlG>�` hereby state that the information I have provided is current,true and correct to the best of my knowle e,and meets the Cal ifomia Health&Safety Code requirements. If the food facility operator tails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the commissary owner shall rptify the EHP immed' el y Signature i O5 Date 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa. uin C.o. The commissary is located in County. The above food facility meets the commissary requirements in California Health & Safety Code. The above checked services are available at the above commissary. Please notify EHD if the status of their operating permit changes. REHS Signature Date 1868 E. Hazelton Avenue I Stockton, Califomia 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd _fl�2sw-icl(C)