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cau_N' <br />°y- SA%JOAQUIN <br />—COUNTY----.,... <br />Greatness <br />Environmental Health Department <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 L <br />COwner/Operator Name <br />Business Mailing Address <br />City <br />StateL —IA—Zip q S 205 Bus <br />Plate # 01M W�/ _9 <br />Alt. Ph. OC 5(6 0q'22-1 <br />I, IY it'll 1,' ' 11WHILID , hereby state that the above information is current, true and correct to <br />the best of my knowledge and agree t6 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 o ice may result in permit <br />revocati d p nalties. 1 l <br />Signature Date <br />Commissary Nam <br />City S1 V Wt C Zip qS203 Owner/Operator <br />Check all appropriate services provided: <br />astewater disposal Zood <br />ompartment sink � ctrical hook-ups <br />S lid waste disposal preparation t�' T ilet and handwashing <br />�� <br />GY Hot & Cold water for cleaning ®ore refrigerated food P table water <br />Store dMURM <br />od/suppliesOvernight parking Vehicle wash <br />I, Eyn , hereby state that the information I have provided is current, true and <br />correct to the best of my knowledgeAudZeets the California Health & Safety Code requirements. If the food facility <br />operator gaicomply h t condition this agreement, or if this agreement is modified or cancelled, the <br />commissV shall t' the EHD im edia ly. I Y C <br />Signature Date Il <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 />