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SAN lOAQUIN Environmental Health Department <br /> _-COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 4, Caterer <br /> Complete sections 1 and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br /> I. To'be.coin I,6tEd -by-APPLICANT .. WKNK <br /> Business Name 6A <br /> Lic. Plate# <br /> Owner/Operator Name �'L <br /> Busine s Mailing Address (-71 ) S IM.r 14 I Al <br /> City State�Zip g215Bus. Ph.S�',S6�bAlt. Ph. <br /> 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 permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation a nalties. <br /> Signa em Date <br /> r <br /> 2,;To b$ com leX d.b. . CQ.MMISSARVO 1(l:El /,OPERAI'QR <br /> Commissary Name Y h rn via # <br /> Addres Y Bus. Phone (� L <br /> City Zip Owner/Operator <br /> Check all appropriate services provided- <br /> wastewater disposal ® 3-compartment sink Electrical hook-ups <br /> �70't <br /> < 'd waste disposal C3'Food preparation 9461 let and handwashing <br /> & Cold water for cleaning refrigerated food Pe�icle <br /> le water <br /> tore dr food/supplies lies Overnight parking wash <br /> Y PP <br /> , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the conditions o is agreement, or if this agreement is modified or cancelled, the <br /> commissary w r shall n tfy the EHD imm i ely. I/ <br /> Signature Date <br /> 3 To be co pl ti sd b 'th ENV HEA►LTk,,� ` % drati`Wou ad %o" SJ.oa �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 />