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SANADANIN <br /> Environmental Health Department <br /> f ` —COUNTY-- <br /> ^e sa <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 A hold or Lic. Plate# 1Z <br /> Owner/Operator Name Inizc2r <br /> 2 (wA -TIS <br /> Business Mailing Address 2 /6 S 1 1 /�6�q <br /> City l"1 r1 bpi State CYCZipO1S236Bus. Ph2 `1� "I WAlt. Ph. <br /> t, , 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 offir ,nay result in permit <br /> revocation an [ties. <br /> Signature_ � Date 417,12� <br /> Commissary Nam Y n eV I IV(/as <br /> Addre <br /> City ZipOwner/Operator &A& r <br /> ;Cheek all appropriate services provided: <br /> Wastewater disposal 12 3--compartment sink LOY/El ctrical hook-ups <br /> Sol' waste disposal Food preparation Ld Toilet and handwashing <br /> i &Cold water for cleaning C1 Store refrigerated food M P/otable water <br /> e d food suppli I.YOvernight parking �Vehicie wash <br /> I, / hereby state that the information 1 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 /> commissaryo all n tn7cuLsimmediately. <br /> . I I <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 ) Stockton. California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.orgiehc <br />