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SAN J O A Q U I N 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 'S Lic. late# p-., <br /> Owner/Operator Name 0� <br /> Busines Mailing Address 2SZO L Y)S <br /> City ►'-r5tateZip S20S Bus. Ph. Alt. Ph. 11 V <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 permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date <br /> Commissary NamNAfd'(10 �— # <br /> Address ' Bus. Phone Z <br /> City Zip Owner/Operator <br /> Check all appropriate services provided: <br /> 'Wastewater disposal 3'3-compartment sink D'Electrical hook-ups <br /> olid waste disposal 0-'Food preparation ® let and handwashing <br /> 0-i4ot & Cold water for cleaning ore refrigerated food L! Potable water <br /> %T01 <br /> re dry food/supplies s�ernight parking ehicle wash <br /> , hereby state that the information I have provided is current, true and <br /> co6kio th st of my k owle ge, and mee 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 ow er shall noti the EHD immedia y. <br /> Signature DateV VV <br /> �) <br /> 3 To by com b <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 />