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` ;. SANdOAQUIN Environmental Health Department <br /> —COUNTY— <br /> . <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility m Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> : <br /> Business Name o D 5�bl —T*w � Lic. Plate#-S&I 5-1 � <br /> Owner/Operator Name <br /> Busi(n s Mailing Address - <br /> City�Stat Zip-qQD us, PhZQ9 £7-q 5 2-1AIt. Ph. <br /> 1. , 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 /> CommissaryNamnne <br /> Add <br /> J • p�Y S Bus. Phone Uc� Ti <br /> City Zip ' 1��� Owner/Operator Y <br /> Check all appropriate services provided: <br /> wastewater disposal E '3-compartment sink V�Electrical hook-ups <br /> Solid waste disposal I od preparation ff Toilet and handwashing <br /> 0--of& Cold water for cleaning 0"Ttore refrigerated food P�o ble water <br /> re dry ood/supplies Overnight parking Vehicle wash <br /> hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledg , 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 pw rer shall n ify the EHD immedyi ly.I/J n� <br /> Signature -�� � ties Date -+ I <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in Califomia 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 />