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SANS MUIN Environmental health Department <br /> --C O U I\T Y--- <br /> A r <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility a Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1�{r+� r y� '��l�A f ,�. ��#� ..�F anY.,� "•'mac i�+� _wzyR� :. <br /> EN, iJ'���Li'l�/1�� '�'�• a' �_b^Y4 t'i i »,� r�::,u mt +.,y +' <br /> ,.• ... .... .. .....•. ,- . . `« np, <br /> Business Name � 1 )DA �� Lia Plate# A <br /> Owner/Operator Name <br /> Busin s Ma'ling Address \S U - <br /> City Stat Zip us. PhZQI Inq 5 9AIt. Ph. <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 NarnQe L <br /> Addres ID J • \ '( S • Bus. Phone G� U <br /> City Zip�_Owner/Operator <br /> Check all appropriate services provided: <br /> wastewater disposal IBJ 3-compartment sink electrical hook-ups <br /> Solid waste disposal Food preparation M. Toilet and handwashing <br /> Plot & Cold water for cleaning IYRore refrigerated food n�Oble water <br /> re dryood/supplies Overnight parking ehicle wash <br /> U AA—hereby state that the information I have provided is current, true and <br /> correct to the best of my knowle g,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 /> commissaryw err shall nil <br /> ify the EHD imme i Iy.I� <br /> Signature I� M VV Date <br /> 3 T ed b` # Jvl;. kt` Tsdra... ttsfef 'f � Wo _ <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 1 Stockton. California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />