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SAN :JOAQUIN Environmental Health Department <br /> t <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility m Caterer <br /> Complete sections 1 and 2. If your commissary is located <br /> ��outside of San Joaquin County also complete section 3. <br /> Business Name ( IZUUplate# <br /> Owner/Operator NameNik9ft J C <br /> Busin s Mail' g Addresslb9C <br /> City�Stat 4Zip g'U3 Bus. Ph. It. Ph. <br /> I, 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 penalties. n <br /> Signature 1\��_� �` � � Date 1/ <br /> Commissa��rryLy1 Nam <br /> Addresslt7 Asi� Sus. Phone /2b I'+- I <br /> Ci9�0 Zi4 <br /> p �Owner/Operator S <br /> Check all appropriate services provideed� <br /> Wastewater disposal 01—compartment sink electrical hook-ups <br /> {//Solid waste disposal PTFood preparation 11 Toilet and handwashing <br /> ❑ of& Cold water for cleaning ❑ Store refrigerated food f3 Potable water <br /> e d food suppli s 113 Overnight parking chicle wash <br /> I, _ & /� �BEwnirJA�l-7/!�hereby state that the information I have provided is current,true and <br /> correct to the best of my IFnowledge, 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 /> Commissao r ail n th HD immediate) . <br /> Signature ry �An Date 2 2 <br /> W Q <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 4640138 1 www.sigov.org/ehd <br />