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r �: SAN 10A0UIN Environmental Health Department <br />I� " —COUNT Y— <br />� Greatness grows here <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 LLLD Lic. Plate # <br />Owner/Operator <br />1,hereby state that the above information is current, true and correct to <br />the be of my knowle ge and agree to utilize my approved commissary in accordance with Califomia 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 />Check all appropriate services provided: <br />Wastewater disposal CV43-compartment sink f"Electrical hook-ups <br />Solid waste disposal iYFood preparation C Toilet and handwashing <br />Hot & Cold water for cleaning O Store refrigerated food Q- Potable water <br />2'�e dray foocVsuppl%s 0-6vernight parking E;,-Ve-hicle wash <br />I, 11 hereby 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 corn ly with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary o�y/trall ngtify th HD immediately <br />Ainnahirw /L .v.•ffi1�J ii <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 <br />1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />