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i<,a• ' ; SANABAOUIN Environmental Health Department �. COMMISSARY AGREEMENT Mobile Food Facility + Caterer Complete sections 1 and 2. if your commissary is located outside-of San Joaquin, County also complete section 3, S Business Name�P� rnE �)NALOALic Plate if Owner/Operator Name 2 ` 'D IV EZ Busine Mailing Address e City State_(,R_Zip Bus. Ph St� d- Alt. Ph. /1 I. r . hereby state that the above information is current,true and correct to the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the commissary is discontinued,the permit holder must notify the EHD. Failure to notify this office may result in permit revocation and penalties. Signatures >tios�c C1^U2 Date— qo 2 �I CommissaryNam r Address r Bus. Phone !� 2 City C Zip_—OA��0Owner/Operator (1rits _ Check all appropriate services provided: Wastewater disposal compartment sink CVflectricai hook-ups _Solid waste disposal (;'Food preparation �et and handwashing 15 Hot& Cold water for cleaning 1❑ Store refrigerated food C�otabie water e d food suppli td'Overnight parking �I,�fiide wash I, hereby state that the information i have provided is current;true and correct to the best of my cnowledge,and meets the California Health&Safety Code requirements. If the food facility operator falls to comely with the conditions of this agreement, or if this agreement is modified or cancelled, the commissary o r ail n Iffy th HD immediately. Signature Date 210� The commissary is located in County. The above food facility meets the commissary requirements in Caiifomia Health & Safety Code. The above checked services are available at the above commissary. Please notify EHD if the status of their operating permit changes. REHS Signature Date 1868 E. Hazelton Avenue I Stockton. Califomia 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.orgiehd