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5ANAMUIN Environmental Health Department <br /> t Coin✓ <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> RANNIPM r: .. <br /> Business Name(SCO LJO/lCID 4-2— Lic. Plate« 006 IN L <br /> Owner/Operator Name C� 2 <br /> Business Mailin Address 1 �W <br /> Ci Stat Zip X I Bus. Ph. Irl CI r2-0 5'Alt. Ph. <br /> 1, 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. <br /> Signature U%_2)r Date 2 <br /> Commissary Name cla C' G"fit� <br /> Addrressls f G( Bus. Phone Z <br /> Cit}f`h (iY' D Y \ Zip Owner/Operator <br /> Check all appropriate services provided: <br /> wastewater disposal 2 3-compartment sink �ectrical hook-ups <br /> p Solid waste disposal mood preparation -07oilet and handwashing <br /> � ry t&Cold water for cleaning O Store refrigerated food J2-Potable water <br /> e d f suppli D'Overnight parking Vehicie wash <br /> hereby state that the information I have provided is current,true and <br /> correct to the best of mynowledge,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 modify d or cancelled, the <br /> commissary o/y��r all n th HD immediatel�y./��ff// I /t <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in Califomia 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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.orgiehc <br />