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SAN J O A Q U I N Environmental Health Department <br /> C O U N T Y.._.._...__. <br /> F L r ci:lT 'sS Prov. <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 /> -4 <br /> Al <br /> F ..u9"o 1�%"` n ,� 4 " y -safe& <br /> ` ;. �rx y <br /> AT,�. r1/ <br /> Business Name T I,. -0 ILic. late# <br /> Owner/Operator Name 1 Y Y n �— <br /> Bus4esailing AddressCity Stat ipBus. Ph. Alt. Ph.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 per it holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation an en C <br /> Signature Date J �� <br /> ,, t W' <br /> Commissary Name hT CfAy 117 A <br /> Addre �l 1 Bus. Phone <br /> t= <br /> City y\ Zip 0 EEO Owner/Operator <br /> Check all appropriate services provided: <br /> �>\/Vstewater disposal e3-compartment sink IZ#�Electrical hook-ups <br /> S !id waste disposal Food preparation �oilet and handwashing <br /> td'Hot & Cold water for cleaning w tore refrigerated food 6 Potable water <br /> G116'( dry food/s plies CYOvernight parking Vehicle wash <br /> I, , hereby state that the information I have provided is current, true and <br /> correct to the best of y knowledge, and meets 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 o ner s II notify the EHD i �Zj <br /> diately. C �1 n <br /> Signature Date 5 , L/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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />