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SAKPJOAQUIN Environmental Health Department <br /> 0.d T <br /> -COU y T Y------- <br /> �: Greatness grows tic-re <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 /> -- - -- -- - - <br /> -7-1 , — ;: -- - — --... <br /> �° t? APDL EuA,i�1T <br /> Business Name Lic. Plate# �[(J <br /> Owner/Operator Name Y I, rA ( <br /> Busines Mail' g Address Z - / <br /> Cit. S to Zip3 Bus. Ph2o Alt. Ph. <br /> I, hereby state that the above information is current,true and correct to <br /> the best of my knowledge an 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 Name �FA# <br /> Add res f_0 Bus. Phone <br /> Cit Zip 2,pOwner/Operator <br /> Check all appropriate services provided: <br /> , <br /> 0-<Nastewater disposal 13-compartment sink Electrical hook-ups <br /> �oli waste disposal UlFood preparation C1Toiletand handwashing <br /> Not & Cold water for cleaning CVStore refrigerated food C Potable water <br /> for dry f d/supplie Overnight parking Vehicle wash <br /> I y hereby state that the information I have provided is current,true and <br /> correct t the best o y knowledge, and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to;-co ply with the conditions of this agr merit, or if this agreement is modified or cancelled, the <br /> commissary oven sh not' , the EH3 immediately. <br /> Signature < -' ��!t Date v <br /> 77 <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 />