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SAN,3lOAQUIN Environmental Health Department <br /> C0U NTY <br /> Greatness grows here. <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 Lic. PI to# <br /> Owner/Operator Name 2 ^ S <br /> Business Mail no Address l "J W U (�_ ,I <br /> City tate Zi � � Bus. Ph. <br /> qS 16g5j Alt. Ph. <br /> I, , hereby state that the above information is current,true and correct to <br /> the best of my knowledge and gree 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 ay result in permit <br /> revocation and pen Ities. � n <br /> Signature Date !iC/ <br /> Commissary Name <br /> u n �,A <br /> Addres Bus. Phone 2 I l <br /> CityAl�_ Zip Owner/Operator <br /> Check all appropriate services provided: / <br /> Wastewater disposal E 3-compartment sink 0 Electrical hook-ups <br /> Solid waste disposal LIFood preparation ;t-Toilet and handwashing <br /> Ct Hot & Cold water for cleaning t3 Store refrigerated food Y15ootable water <br /> ® Stor dry f d/suppli vernight parking C vehicle wash <br /> I, , hereby state that the information I have provided is current,true and <br /> correct o the best of my k ledge,and meets the California Health &Safety Code requirements. If the food facility <br /> operator fails to comply with the condi 'ons of this agreement, or if this agreement is modified or cancelled, the <br /> commissary caner shall notify the EH i mediately. <br /> Signature 11 Date L <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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />