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-�- WAWA ° ;r� � �r �a� � ��tt� Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections 1 and 2. If your commissary is iocated outside of San Joaquin County also complete section 3. <br /> Business Name Lic. plate# r 2Z <br /> Owner/Operator Name <br /> Busin„ s Mal Ing Address <br /> Gity teiea ZipSus. It, Ph. <br /> 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 muni notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. I <br /> Signature _StVY9 e C I rS n e ress � �Daty <br /> Commissary Nam rr <br /> Address• 7 U11BUS. Phone~ <br /> City Zip Owner/Operator . <br /> Check all appropriate services provided <br /> Jdastewater disposal -0-3-compartment sink 12191ectrical hook-ups <br /> MoSolid waste disposal E3—Food preparation M�T­oiiet and handwashing <br /> t'Hot& Cold water for cleaning store refrigerated food M-Potable water <br /> Store dry food/supplies vemight parking UA fal Cie wash <br /> 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 t mpiy with the conditions of this agreement, or if this agreement Is modifed or cancelled, the <br /> commissary o1 er 11 nol'fy the tD immediate[ <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 /> REHS Signature Date_ <br /> 1868 E. Hazelton Avenue I Stockton. California 95275 ; T 209 468-3420 1 F 209 484-0138 1 wVvw.sjgov.org/ehd <br />