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-- <br /> =' <br /> ' ~ S & NIJOAMBIN <br /> Environmental Health Department <br /> ^ —,cC�oO�sU�wr�TpY� - <br /> COM�e M <br /> xSSARY 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 /> � <br /> Businqss Melling Address u) kf� k?j- 4- <br /> State <br /> | anobystate that the above information iscurrent,true and correct to <br /> the Vedtc* nnyknowledge XdoOneeGutiVzomyapproved commissary inaccordance with California Health & <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary indiscontinued, the permit holder must notify the EHD. Failure tonotify this offinemay result inpermit <br /> revocation and penalties. <br /> SignDate 10 <br /> Check all appropriate services provided: <br /> a/Wastewater disposal 0--3--compartment sink W/Electrical hook-ups <br /> Ho & Colld water for cleaning Stoje refrigerated food W�P able water <br /> ���� <br /> � �hidewash <br /> | <br /> hereby state that the information | have provided iscurrent,true and <br /> conncxon�oeVeotc�nnyknovNeVge.and meets the California Health&Safety Code requirements. |fthe food facility <br /> ope:otor%ai|a �oc | with the conditions of this if this i di� e <br /> commissary <br /> SignatureDate <br /> � - '- - ' / | <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 EMDifthe status oftheir operating permit changes. <br /> REHS Signature Oat <br /> 1808EHazelton Avenue | Stockton. California 952051T203408'342V1 IF2O9404'V138 / wxww.sjgov.urg/ehd <br />