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k SA 6J OAQ U I N Environmental Health Department <br /> C 0 u N T Y_._._._ <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 1/ Lic. Plate# <br /> Owner/Operator Name Y ( ez' <br /> Busines Maili g Address 2 - <br /> Cit S to Zip qS2_03 Bus. Ph.c.kl� qq3j?10fVAIt. Ph. <br /> I, hereby state that the above information is current,true and correct to <br /> the best of my knowledge and a ree 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 and penalties. <br /> Signature s Date <br /> Commissary Name �A# 20 <br /> Addre sTIDID1`(/1 Bus. Phone <br /> Cit zip0� <br /> ' Owner/Operator C� l 0)� (^ <br /> Check all appropriate services provided: �/ <br /> �1lastewater disposal 05 <br /> " 3-compartment sink �Electrical hook-ups <br /> �oli waste disposal �od preparation �QToilet and handwashing <br /> Hot & Cold water for cleaning G}�Store refrigerated food C -Potable water <br /> 1121--55foxdry f d/supplie Overnight parking Vehicle wash <br /> I r , hereby state that the information I have provided is current,true and <br /> correct t the best y knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to o ply with the conditions of this agr merit, or if this agreement is modified or cancelled, the <br /> commissary o s noti the immediately. 4 /I <br /> Signature .. � Date v / <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 />