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S A N ) Q A Q U I N Environmental Heath Department <br /> v U i'-4 <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 /> 1. To be completed by APPLICANT <br /> Business Name 62l-1--cd Ca'tc Lic. Plate#_'V\ -,2Abq <br /> Owner/Operator Name <br /> Business Mailing Address %4�111 \A 16A%-or\ R-ca <br /> City StateLtZip T53oA Bus. Ph. Qoq-Soo-�51-1 Alt_ Ph. 'ao°1- <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 holster must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature r Date - '6 al a 1Q <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name -'�^L FA# <br /> Address Bus. Phone e C. r .,Z. t- E� J <br /> City Zip s ZL t� _QwnerlOperator c' <br /> Check all appropriate services provided: <br /> 4 Wastewater disposal 3-compartment sink ;?Zfi Electrical hook-ups <br /> Solid waste disposal Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning Q Store refrigerated food Potable water <br /> Store dry food/supplies l( Overnight parking Vehicle wash <br /> )E�"r_ CQ, hereby state that the information I have provided is current, true and <br /> correct to the best of my kadwieage,and meets the Califomia 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 _pate { l 1�1 <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,sjgov.org/ehd <br />