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.ioqt GOAQUI __ ;; menta} Health Depart^kerrt <br /> C 0 u ti . ---- <br /> Grectint-ss grows <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility z Caterer <br /> Complete sections 1 and 2. !f your commissary is located outside e7 San Joaquin County also complete sec. On <br /> #- ..- •. - -, r ............. .y,+G <br /> Business Name ( —_ �U kly�Iate#r <br /> Owner/Operator Name J C <br /> Busin ss Mail g Address 0 �� <br /> Clty n qAj <br /> Stat Zp Bus. Ph. It. Ph. <br /> 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 peraities. ✓ n <br /> Signature_ �3'` Date <br /> Commissa Nang G <br /> Address-1 - Bus. Phone 1 <br /> Ci Zip Owner/Operator f�� <br /> Check all appropriate services provided: <br /> Wastewater disposal 0"53-compartment sink electrical hook-ups <br /> i:-5-olid waste disposal Food preparation Toilet and handwashing <br /> of& Cold water for cleaning Store refrigerated food ~potable water <br /> £� S" e d food suppii s rovernight parking vehicle wash <br /> I, � � '.'A hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledge. and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to com ly with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary opeTall n th HD immediately11 . <br /> Signature Date 2 <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 T 209 468-3420 i F 209 464-0138 1 www.sjgov.orgiehc <br />