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' <br /> � & k� �� & ���� ���^���������� ������� Department <br /> ��»ent <br /> �f ��r�*"wv `�r,~r�^ ,, � Environmental ^__ _ <br /> [0UNTy-- <br /> / G'?o1 o,� <br /> COMMISSARY AGREEMENT <br /> �*��xnvxnvo����x–�u� ox~���u���u~xnou`n� o <br /> Mobile Food Facility + Cate[er <br /> Complete sections / arid 2 If your commissary is located outside of San Joaquin County also complete section 3. <br /> Busi Mail n Address <br /> | hereby state that the above informationiscurrent, true and correct 8> <br /> th -si of m; knogedge e'nd 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 /> commissaryidiscontinued, notify this office may result inpermit <br /> revocation and penalties. 1�/5 <br /> Signature Qate <br /> 0-1,wastewater disposal a53-compartment sink O/Electrical hook-ups <br /> P--s'ofid waste disposal �Zood preparation Toilet and handwashing <br /> o cCold water for cleaning St refrigerated food P9 3ble water <br /> �Overnight parking hicle wash <br /> |. . hereby state that the information Ihave provided incurrent,true and <br /> correct to the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails t ly with the conditionsagreement ismodified or cancelled, tho <br /> commissarythe/E�­!D immediately, <br /> Sign Date ho <br /> 010 <br /> The commissary iolocated in County. The above food facility meets the <br /> commissary requirements inCalifornia 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 /> REHSGignatu —Date <br /> 10O8E. Hazelton Avenue I Stockton. California 05205 | T 209488'J4201 F 209404'8150 ivwmm.sjgvv.org/ehd <br />