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s_ SKJOAOUINEnvironments( Health Department <br /> <' COUNTY— <br /> tLo7v� Gres>ness grc.r= here. <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 /> Business Name Lic. Plate# ! Z <br /> Owner/Operator Name <br /> Business Mailing Address 2 <br /> City State l Jt]Zip Bus. Ph p Alt. Ph. <br /> IA 1A �Tereby state that the above information is current,true and correct to <br /> the best o my kno edge agree o uti ze 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 and pen it' <br /> Signaturt�vis Date ( I <br /> Commissary Nam r h <br /> Addres. amBus. Phone <br /> City Zip� _Owner/Operator <br /> Check all appropriate services provided: <br /> O'Wastewater disposal r3-'compartment sink CL-Efectrical hook-ups <br /> olid waste disposal Food preparation Ck'foilet and handwashing <br /> k Plot & Cold water for cleaningstore refrigerated food r 'Pota water <br /> Q <br /> te d food suppli s O Overnight parking ehicle wash <br /> I, hereby state that the information I have provided is current,true and <br /> correct to the best of my mowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to com ly with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commiry ssa o6r. <br /> r all nncall th HD immediately. <br /> Signature .rir //fi ,� DateL _ <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 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />