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CAUIq�r <br /> � s <br /> SANdOAQUIN Environmental Health Department <br /> —COUNTY---- <br /> 1.4 <br /> COU NTY_ -- <br /> �,►►r�,,�TM' Greatness rows ner2. <br /> -Mc,<ca 9 <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 /> NOW OEM OEM <br /> ` l <br /> a <br /> Business NameLic. Plate# <br /> Owner/Operator NameY <br /> Busine s Mail'n Address e <br /> Clt <br /> it State(9—Zip �, Bus. Ph It—Alt. Ph. <br /> I, hereby state that the above information is current,true and correct to <br /> the best bf my knowledge a 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 /> revocatiod penaltie . <br /> Signature Date <br /> Commissary Name ' Y h I' <br /> Address n us. Phone <br /> City Zip Owner/Operato0 FO* <br /> Check all appropriate services provided: <br /> � <br /> wastewater disposal CV! -compartment sink �ectrical hook-ups <br /> ��Solid waste disposalQlFood preparation �/Toilet and handwashing <br /> E Hot & Cold water for cleaning lr Store refrigerated food ;/Vehicle <br /> P, le water <br /> ® tore dry foo /suppli vernight parking wash <br /> I, � , hereby state that the information 1 have provided is current,true and <br /> correct to the best of my k owledge,and meets the California Health &Safety Code requirements. If the food facility <br /> operator fails o comply with the condi ions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary ner shall notify the E mmediately. <br /> Signature I 142,14 Date <br /> h <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 /> RENS 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 />