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' * <br /> ~� ^ronwwnmp� Health Depa" u" "�n^' <br /> �A i X <br /> '— <br /> —C[ UNTY-- <br /> COMMUSSARY AGREEMENT <br /> Mobile Food Facility ^, Caterer <br /> Complete sections 1and 2 If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> Owner/Operator Name &6a(A <br /> Business Mailing Address mN�u—1v <br /> 1, ., 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 discgntinued the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and&�alt�ies. e_':� <br /> Signatu�r �- Date <br /> 12. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name J.-vm '8"0/y- FA# <br /> Address IMI <br /> Bus <br /> Zi <br /> Check all appropriate services provided: <br /> ��Wastewater disposal ���� 3-compartment oink �� Electrical hook-ups <br /> �� <br /> So|id waste disposal Food preparation Toilet and hondvvoahing <br /> �� Hot & Cold water for cleaning Store refrigerated food Potable water <br /> Store dryfood/supp|ios Overnight parking Vehicle wash� <br /> hereby state that the information | have provided is ournsnt,true and <br /> correct to the best ofmyknowledge, and meets the California Hea|th &Safe1yCodeequin*mentu. |fthe food facility <br /> operatorfails to complywith the conditions of this agreement, or if this agreement is modified or oonoe||ad the <br /> Signature Date <br /> 13. To be com leted b th HEALTH 'urisdiction 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 Coda. 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 Stookton, California 95205 1 T 209 468-3420 1 F 2O9464'0138 1 vmww.sjguv.org/ehd <br />