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~ � �� Environmental Health Department <br /> COUNTY <br /> �Qtz,=a��' vreC'nass y�4.ss rare. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections 1 and 2. ff your commissary is located outside of San Joaquin County also complete section 3. <br /> Business Name _ —NUMLic. Plate# 3�' �- <br /> Owner/Operator Name e YN <br /> Busin s Mailing ddress <br /> Ci State Zip -q lQSus. Pt S E" fl h. <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 discon ' ued, permi holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and pen es. t n 3 � 12-D <br /> Signature Date l L� <br /> Commissary Name q ; <br /> Address Bus. P e L� <br /> City Zip 2.� OwnerlOperator <br /> Check all appropriate services provided: <br /> 11 <br /> Wastewater disposal Cr'-3--compartment sink �ectrical hook-ups <br /> Solid waste disposal �ood preparation toilet and handwashing <br /> ��HiotCold water for.cleaning 0-9tore refrigerated food CP-Pbotable water <br /> d food suppii �ernight parking $$vehicle wash <br /> I, hereby state that the information l have provided is current,true and <br /> correct to the best of my nowfedge,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 r all n th HD immediately. 44 <br /> Signature Qate 1 <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 � .Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />