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i� jj kktt <br /> 3 �AJ E ��i� l' ir4��%ment6l Health Departma t <br /> —COUNTY-- <br /> COMMISSARY <br /> COUNTY-- <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 /> �v <br /> Business Name e.5 0r I W Ae& Lic. Plate f <br /> Owner/Operator Name <br /> BusinessMailing Address C C! <br /> City / Stat Zip Bus. P 2 Alt. Pf „ 3 � <br /> 1, eaYo 12 ocl r' �Z— hereby state that the above information is current,true and correct to <br /> the best of my knowledg 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 <br /> thholder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and p na��� <br /> Signature Date Z <br /> Commissary Nam L n <br /> Address rBus. Phone /� <br /> City Zip�Owner/Operat <br /> Check all appropriate services provided: <br /> wastewater disposal D- Tcompartment sink �� Electrical hook-ups <br /> [3/Solid waste disposal �ood preparation - 'Toilet and handwashing <br /> I Ho/t&Cold water for cleaning C7 Store refrigerated food Potable water <br /> CSS e d food/suppli td'Overnight parking icle wash <br /> 1, hereby state that the information I have provided is current,true and <br /> correct to the best of my mowledge,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 modified or cancelled, the <br /> cogmmissary o all n ttfy ih D immediately. <br /> Si nature � Date <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 1 Stockton. California 96205 4 T 209 468-3420 1 F 209 464-0138 ; www.sjgov.org;ehc <br />