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SAN ( Q 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 VS <br /> C� LA Lic. late# <br /> Owner/Operator Name <br /> d1 �- <br /> Busines Mailing Address 2SZO - �' ,- <br /> City ►^Ptate_C"ip q 616 Bus. Ph. Alt. Ph. b <br /> I , hereby state that the above information is current,true and correct <br /> the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br /> & <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 esult in permit <br /> revocation and penalties. 2� <br /> Signature_�v� <br /> Date <br /> Commissary Nam n ` <br /> Address ' - Bus. Phone 2 <br /> City zip Owner/Operator <br /> Check all appropriate services provid_e�d: <br /> �IVastewater disposal C3'3-compartment sink 0-Electrical hook-ups <br /> alS'Olid waste disposal C]­'Food preparation CY'ilet and handwashing <br /> Eft & Cold water for cleaning 13181tore refrigerated food E Pota to water <br /> i ht parking ehicle wash <br /> %re <br /> e dry food/supplies 13 Vern g p g <br /> hereby state that the information I have provided is current, true and <br /> th st of my k ow <br /> ge, and ee 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 owjr shall noti the EHD immedia Y. ^ „ n <br /> Signature <br /> Date 4 <br /> �- <br /> I Now <br /> Will <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 />