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SAN JOAQUIN Environmental Health Department <br /> T _ ___....._. <br /> COUNTY <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 /> ,��� ��.T4�s;: , ,: s �,�� '✓"{ � l"� Y1lr+' 1 "tip <br /> k <br /> „G. ,n./,i.1. Y .F° .'✓. ii ' .. �%� <br /> H <br /> Business Name0 L Lic. Plate# <br /> Owner/Operator Name Y -eY —L— <br /> Busine s Mailing Address <br /> City StateCAlip _Bus. Ph. Alt. Ph. fo <br /> I 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 discontinued, the per it holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation an en .lti <br /> Signature Date J �� <br /> Commissary Name f r Y 1 <br /> Addre d1 1 - Bus. Phone 2 <br /> City -Y\ Zip G Owner/Operator <br /> Check all appropriate services provided: <br /> [W stewater disposal 0r3-compartment sink O(Electrical hook-ups <br /> Solid waste disposal Food preparation Toilet and handwashing <br /> Gd'Hot & Cold water for cleaning w tore refrigerated food 6 Potable water <br /> Store dry food/s plies V' -6vernight parking Vehicle wash <br /> I, O , hereby state that the information I have provided is current, true and <br /> correct to the best of y knowledge, and meets the California Health &Safety Code requirements. If the food facility <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary o ner s II notify the EHD im diately. e n <br /> Signature - Date S L� <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 />