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^ ~ <br /> `'- <br /> `� O AHMJ W <br /> Environmental Health Department <br /> �AN <br /> COUNTY— <br /> Grastnco grows here, <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections 1and 2. Ifyour commissary is located outside ofSan Joaquin County also complete section 3. <br /> MP <br /> Business Name —Lic. Plate 0` <br /> Owner/Operator Name <br /> Business Mailing Address <br /> I, - reby state that the above information is current,true and correct to <br /> the best of my kp(owledge and agree to utirize 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 /> revocationld,p,en, lti�� <br /> Date <br /> Signature <br /> [2. T6qaid-Com�letedbyCOMMISSARY,OVVNER/,,OPE ;PA,-T <br /> Address <br /> Bus. Phone �2 52 7 <br /> Check all appropriate services provided: <br /> WWanzevvozmrd/sposo| P~r-nonnpodrnenteink 9-E|ecthcm| houk-ups <br /> �A�n||Uvvaetodiaposa| U'f-6odproparotion O—TJD�Fandhondvvashing <br /> P_<0t & Cold water for cleaning Ci-15tore refrigerated &-P <br /> -otable water <br /> dry f d/ lies W-6—vernigl-t parking Vkvehicle wash <br /> _20 <br /> U1 e-a44!21:�_ hereby state that the information I have provided is current,true and <br /> correct tothe best of my knowledge, d meets the California Health &SafeCode requirements. ` <br /> operator fails to ply with the condition&of this agreement, or if this agreement is modified or cancelled, the <br /> Ir <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 EHOifthe status oftheir operating permit changes. <br /> REHS Signature Date <br /> ` <br /> 1868 E. Hazelton Avenue I Stonkton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 vmww.sjgov.org/ehd <br />