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. . <br /> D & ^N <br /> Environmental Health °epa�=meSAN <br /> -� <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility � Caterer <br /> Complete sections Iand J. If your commissary is located outside of San Joaquin County also complete section 3. <br /> Citv00!W(_)64 N-\ State Z qLLIL2 .Bus.,� <br /> 11 hereby state that the above information is current,true and correct to <br /> ite74 <br /> the best of my knowledge and agrpe 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 penalties. ' <br /> Signature %LZA IQ -Date <br /> NN <br /> Commissary Nadm 1 1 61 IC-n 'iQ� j NIL <br /> zip Owner/Operator W <br /> Check all appropriate services provided: <br /> 23,_-3-compartment <br /> = � <br /> rr'�« aotevvaterdiapoaa( i��J-oonnpa�nnentaink �5~�/ecthoa| huok-upa <br /> waste disposal 2r�Foodpreparation ;a'Tioi|etand handvvash|ng <br /> � � �� <br /> Q�f��� @Co|d water for cleaning �� � refrigerated�rigerated food �"_�otab|e water <br /> E d/ry foodjsup2pfi s a_�J­Gv_ernight parking ,- /rehidevveoh <br /> |. <br /> hereby state that the information | have provided is oumynt,true and <br /> correct tothe best ofm knowledge, and meets the California Health&Safety Code requirements. |fthe food facility <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> Signature c., Date f) <br /> IT -NA <br /> Or <br /> 111 WHO <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code, The above checked oominee are available at the <br /> above commissary. Please notify EHO if the status of their operating permit changes. <br /> REHSSignatur Date <br /> 1838E. lHazeitonAvenusI Stock'ton. Co)>fomisA52O5i T 2O8488-342O1 F 209 464-0138 1vmmwv.sjgov.crg/ehd <br />