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ra EnSANJOANIN <br /> vironmental Heath Department <br /> t <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility a Caterer , <br /> Complete sections 1 and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br /> '` ��yn� VlJCJ � l4i� ,,,' 15`.� <br /> rr.£isv-...:r��r.,,_....n <br /> Business Name S c. Plate#3ZSs <br /> Owner/Operator Name WI AIT� (e <br /> Busin s Maili//ng ddress �otI QQ �t Q QQ qq <br /> City L a Zip S� Bus. Ph. T6 9 � V Alt. Za� S UL-I <br /> i, allMp 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 discontindbdy the ermit holde ust notify the EHD. Failure to notify this o ice may result in permit <br /> revocation and pe at i <br /> Signature Date 2 b ? <br /> Commissary Name <br /> 20 2 <br /> Address Bus. Phone <br /> Cit ( jU�c ZipOwner/Operator <br /> Check all appropriate services provided: <br /> M-Wastewater disposal compartment sink U�Electrical hook-ups <br /> 0-9-olid waste disposal 121�Food preparation Ef Toilet and handwashing <br /> Hot& Cold water for cleaning LI'§ore refrigerated food 13—Potable water <br /> �e d food suppli s 0-Overnight parking chicle wash <br /> I, Qk<44eAd hereby state that the information I have provided is current, true and <br /> correct to the best ooffypmpy <nowledge, and meets the Califomia 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 mall n tffy th HD immediately. l <br /> Signature � �. immediately <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 209 464-0138 1 www.sjgov.orgiehd <br />