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SA N J OAQ U I N Environmental Health Department <br /> COUNTY ... .._ <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 t ' Lic, Plate# <br /> IL <br /> Owner/Operator Name J , <br /> Business Mailing Address 1 <br /> city_ L State-f_AZip 5 Z 0 Bus. Ph. Alt. Ph. <br /> Ij. G 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 amend+ penalties. f <br /> Signatur Date 6 9- <br /> Commissary Name FA# <br /> Address_ Z� � z �.,,� Bus. Phone -ZD z Zv-9,S-5y <br /> City Zip. 2 yy Owner/Operator <br /> Check ll appropriate services provideed:� <br /> jpAvastewater disposal 0-3-compartment sink P-19115-11 trical hook-ups <br /> Iolid waste disposal ood preparation To et and handwashing <br /> jV/Hot & Cold water for cleaning 0 St re refrigerated food Potable water <br /> tore dry food/supplies Overnight parking 0-Vehicle wash <br /> !, hereby state that the information I have provided is current, true and <br /> correct t t e 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 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 i www.sigov.orglehd <br />