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S A N J O A Q U I N Environmental Health Department <br /> --COU NTY-- <br /> ,, Greot,iess grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility * Caterer <br /> Complete sections 9 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 JL I ►1 Lic, Plate# <br /> Owner/Operator Name(. (('A, i <br /> Business Mailing Address�.��5't" <br /> City State( Zip �' Bus, Ph. Ir L74 -bt Z'�AIt. Ph. <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 an enal Is. <br /> Signature Date 1-2— 2- <br /> - <br /> 2. To be completed b COMMISSARY OWNER/OPERATOR <br /> Commissary Name C& I)Glt Y) 4£+"►n. FA# <br /> Address 90 S. 1 f oor gt) Bus. Phone Zo cl — 9 6 ! — I!fib. <br /> City c,-*v JlC wit Zip 1�G C. OwnerlOperator <br /> Check all appropriate services provided: <br /> Wastewater disposal Z�3-compartment sink IN Electrical hook-ups <br /> Solid waste disposal 10 Food preparation Q� Toilet and handwashing <br /> Hot & Cold water for cleaning ® Store refrigerated food El Potable water <br /> f$1'Store dry food/supplies M Overnight parking ST Vehicle wash <br /> ZV6I y hereby state that the information I have provided is current,true and <br /> correct tote 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 notify the EHD immediately. <br /> Signature Date <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 />