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SAN J OAQ U I N Environmental Health Department <br /> 0U t � <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 SI,Y) L� Lic. Plate <br /> Owner/Operator Name <br /> Busine s Mailing Address � & ree ' <br /> City L Y) StateCjo_Zip��Bus. Ph. Q It. Ph. <br /> I14S 1,�l_ , 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 pe Ities. <br /> S(/� t V��— Date SCJ <br /> Signature �i (� <br /> f ed' tSl\YfE� IE <br /> x <br /> Commissary Name Y), C�L' Aikd <br /> Address � Bus. Phone 2 Lk <br /> City Zip J 1� Owner/Operator <br /> Check all appropriate services provided: �/ <br /> �lastewater disposal 1211-compartment sink 11: Electrical hook-ups <br /> 12--s-0—rid waste disposal ood preparation 112-foilet and handwashing <br /> E Hot & Cold water for cleaning tore refrigerated food #3!Po le water <br /> s <br /> e d su li ht parking ehic <br /> food pp s vernile wash <br /> rY 9 <br /> I, hereby state that the information I have provided is current,true and <br /> correct to the best of my nowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to corn ly with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary o r all n 'fy th HD immediately. 1� �� <br /> Signature Date <br /> 3" cWe <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 I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />