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SAN JOAQUIN Environmental Health Department <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 /> Business Name ! INIRUclate# <br /> Owner/Operator NameQKM J C <br /> Bus* s Mail- g Address C <br /> City r,�A)gstat Zip qJU3 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 \ � ` �'l� Date 1/ <br /> Commissary Nam <br /> yr V✓' I <br /> Addressq – Bus. Phone 2 l <br /> Ci Zip 0�� 3 Owner/Operator S <br /> Check all appropriate services provideed� <br /> Wisastewater disposal 3-compartment sink electrical hook-ups <br /> 2 Solid waste disposal @Food preparation 11—T-oilet and handwashing <br /> 1.3 of& Cold water for cleaning ❑ Store refrigerated food O'Potable water <br /> ❑ S e d food suppli s (3 Overnight parking chicle wash <br /> �� h e.,rhereby 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 o r all n th HD immediately.,r i <br /> Signature cc�,�An�, Date Z 2 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 952051 T 209 468-3420 1 F 209 4640138 1 www.sigov.org/ehd <br />