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,SANA0AOUIN Environmental Health Department <br /> OUNTY— <br /> �,�. l^',�:+J <br /> �� �sreCfres3 grc sr5 <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. Plate <br /> Owner/Operator Name <br /> Business Mailing Address <br /> CityAtA5nState�Zipf��(�Bus. Ph. d njSjAlt. Ph. <br /> 1144 1 hereby state that the above information is current,true and correct to <br /> the of my know) 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 penaJbgs. <br /> Signature <br /> 11' `J Date <br /> Commissa jNNamfN <br /> Addressn Bus. Phone !=a l <br /> City Zip�Owner/Operator <br /> Check all appropriate services provided: �� <br /> a ewater disposal C}-3'c &��empartment sink lectrical hook-ups <br /> Solid waste disposal Food preparation Ct Itoilet and handwashing <br /> E�lot Cold water for cleaning �or refrigerated food 0-P ble water <br /> Store dry food/supplies vemight parking Vehicle wash <br /> 1 , hereby state that the information I have provided is current,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 tg,5bmply with the conditions of this agreement, or if this agreement is modfi or cancelled, the <br /> commissary of er I 11 no' the D immediately. <br /> Signature _Date <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 />