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9-f. <br /> SANP10A0UIN Environmental Health Department <br /> . ` --COUNTY- <br /> 1 Greotness grows here. <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 /> s4: Tn be}coin 1+?>eci;b AP.P1=ICANT_,H� <br /> 1 <br /> Business Name l L Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address // <br /> Ci State AZip� Bus. PhlD� �W]V 7.4AIt. Ph. <br /> 1, , hereby state that the above information is current,true and correct to <br /> the best V my knowledg agree o 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 /> revocatin and penalties. <br /> SignaturDate ! 26L_�D <br /> 62 he corn le ectYb GOIUIMI S RX OWREW0,411.E TOR "" :°5 " <br /> Commissary Nam <br /> Address us. Phone <br /> City ZipOwner/Operator r <br /> Check all appropriate services provided: <br /> 113�_Wastewater disposal Zf 3 compartment sink Er"E-1'ectrical hook-ups <br /> O Solid waste disposal rood preparation ErT—oilet and handwashing <br /> $riot Cold water for cleaning ZI Store refrigerated food potable water <br /> S e d food suppli s 0-overnight parking ehicle wash <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 comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary oyy r all n fy th HD immediately <br /> Signature Date o I bk. <br /> 31'_a be.com ieted: s fle`,ENVEAt f.} "u'ffsd etion otitsrdetof;Sari to tan Co <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 />