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1= SAG OAQ U I N Environmental Health Department <br /> COUNTY <br /> Greatness grows here, <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility m Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> .'�. a{ s <br /> 3, T <br /> �• ,r ; r eRs°„ zs x x �� 's, e, <br /> Business Name Lic. Plate# <br /> Owner/Operator Name ~<) rD <br /> Busi ess Mailing Addr ss 532 V (l_n eir <br /> Cit to &hZip Bus. Ph2P9Q?_8 _Alt. Ph. <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 Env' ealth Department (EHD) requirements. If the use of the <br /> commissary is discontinued, the permit Ider must notify EHD. Failure to notify this office may result in permit <br /> revocation an enalties. <br /> Signature Date )DD <br /> 1 2_To be com et byb r_COMMISSARY OW ERIOPERATOR <br /> Commissary Na ITID f CA jwl,GYN"Ifl -2�Q l� -1 <br /> Addres - n T Bus. P on <br /> City �' Zip S� Owner/Operator t( <br /> Check all appropriate services provided: <br /> Wastewater disposal �0/-compartment sink Electrical hook-ups <br /> Er-s--olid waste disposal G3 Food preparation ta'o let and handwashing <br /> t:'H old water for cleaning Zernight <br /> refrigerated food 015-otable water <br /> re dry ood/supplies n parking O Vehicle wash <br /> I, , hereby state that the information I have provided is current, true and <br /> correc to the best of my knowle ge, 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 er sh notify the EHD i ediately. <br /> Signature Date W�113D <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San joaqu n Co. <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 />