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SANxIGAOUIN Environmental Health Department <br /> l.i.irtif i.Hy$ tF <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility s Caterer <br /> Comptat to sections I and 2. Ifyour <br /> cc.omm�misrsery is located outside of San Joaquin County also complete section 3. <br /> a14R '/G1 <br /> Business Name eS r I W e& Lic. Plate#_U k > <br /> Owner/Operator Name <br /> Busines Mailing Address C e, a _ <br /> City // L stat ZipBus. P S J�E Alt. Ph 3 L 2 <br /> I; er, or hereby state that the above information is current,true and correct to <br /> the best of my knowiedg 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 andp na� <br /> SigmaYurDate Z <br /> :.o <br /> Commissary Nam � � L _ n <br /> Address Bus. Phone 2 _ <br /> City Zip--�� Owner(Operat <br /> Check a4. appropriate services provided: <br /> Vlestewaterdisposal compartment sink EIectricalhook-ups <br /> E3 Solid waste disposal �ood preparation -6 Toilet and handwashing <br /> ` Hoott& Cold water for cleaning £I Store refrigerated food Potable water <br /> LAS e d food suppli s 2- vernight parking icle wash <br /> I, r hereby state that the information I have provided is current.true and <br /> correct to the best of my Knowledge,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 /> commissary o s all ncffy th HD immediately. <br /> Signature �. '�� 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 /> RENS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton; California 352105 j T 209 468-3420 1 F 209 464-0133 1 wv&.sjgcv.orgrehd <br />