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^ <br /> 7 8 J� UAMM IN <br /> Environmental Health Department <br /> ' ---[C}UNTY'-- <br /> � <br /> COMMISSARY AGRE ~M ~NT <br /> Mobile Food FG[j|itv + Caterer <br /> Complete sections Iand 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 Lio. P|ate <br /> Owner/Operator Name <br /> Business Mailing Address <br /> Cit State-LAZip Bus. Alt. <br /> |. . hereby state that the above information iacurrent,true and correct io <br /> the best ofmy knowledge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin County Environmental Health Department (EHO) requirements. If the use of the <br /> commissary iediscontinued, the permit holder must notify the EHO. Failure tonotify this office may result inpermit <br /> revocation and penalties. <br /> Signature —Date <br /> 12. To be completed by COMMISSARY OWNER/OPERATOR <br /> ame <br /> Address s" 4 1' NIJ <br /> Check all appropriate services provided: <br /> disposal Ek-5-'compartment sink WBeothno| hook-ups <br /> � 0"'Food[�� Solid waste disposal ux Food prepanation [3 |oi|etand handvvanhing <br /> O/Holt <br /> & Cold water for cleaning e refrigerated food 13"lPotab|e water <br /> _-�� _'� _—~�- <br /> �� Stora dryfood/supp|ies �� Ovornight parking � Vehicle wash <br /> |. hereby state that the information | have provided iscurrent, true and <br /> correct'to thetest 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 agneement, or if this agreement is modified or oanoe||ed, 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 <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 EHDifthe status oftheir operating permit changes. <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I 8took1on, California 95205 1 T 209468-342U 1 F 209 464-0138 1 www.sjgov.org/and <br />