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_ r <br /> SAWAANIN Environmental Health Department <br /> . <br /> —C o u tJ T Y---- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility a Caterer <br /> Cempiete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete Section 3. <br /> ' t�� rom ieled APPLICANT � 1 <br /> Business Name Lie.Plate# T J / <br /> Owner/Operator Name <br /> Busines Mailing Address �e <br /> City. tate_Z Bus. P <br /> 1, + hereby state that the above information is current,true and carred 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. V, IT <br /> Signature / L Date <br /> 2- fo a Completed GdArtWSSARY (3llOffiRIOP€GATOR <br /> Commissary Nam <br /> Address r 111 G Bus. Phone <br /> City C Zip�Owner/Operator V� t v <br /> WChe k all appropriate services provided <br /> astewater disposal 0Q'33ccompartment sink �lectricai hook-ups <br /> f— 1/lid waste disposal l,a Food preparation EToiiet and handwashing <br /> t2'Hot& Cold water for cleaning ❑ St re,refrigerated food UrPotabie water <br /> Store dry foodisupplies Ovemight parking ehicie wash <br /> t 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 iy with the condi ions of this agreement, or 'rf this agreement is mod', or cancelled, the <br /> commissary0 sh$i otify HD' ediateiy. n <br /> Date G <br /> eo feted by fne ElV1/ t=#iITW jurisd n,,O side of San JOaq ifs Gc� <br /> The commissary is located in County. The above food facility meeis 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 /> 1968 E. Hazelton Avenue I Stockton, Califomia 95205 1 T 209 468-3420 1 F 209 464-0138 !www.sjgov.orgiehd <br />