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, ,.. .. SANAOAQUIN <br /> Environmental Health Department <br /> ' q p Grea!,i"ss 9!lews !fere. - <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 /> 1. To be`WM leted by APPLICANT <br /> Business Name I II C 1 C4 rl 0,1 n ic.Plate# <br /> Owner/Operator Name <br /> Busme s Mailing Address <br /> City5StatefAZip!j4�Bus. Ph2Z Att. Ph. <br /> I, 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 office may result in permit <br /> revocation and penalties. <br /> Signature Date <br /> 2. To be completed b' COMMISSARY OWNER/OPERATOR <br /> Commissary Nam 1 <br /> L.Address � h l Bus. Phone . <br /> City L Zip SQOwner/Operator Mo '7�f v <br /> Ch7K all appropriate services provided:Wastewater disposal . U'3-compartment sink I2'�Electrical hook-ups <br /> � olid waste disposal Food preparation B'Toilet and handwashing <br /> CV14-�ot& Cold water for cleaning Q St re refrigerated food ,Potable water <br /> Store dry food/supplies Overnight parking ehicle wash <br /> 1, ' 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 ly with the conditions of this agreement, o if this agreement is modified or cancelled, the <br /> commissary sh otity HD' ediately. <br /> SignDate <br /> . To be.eom` lefed b" the ENV HEALTH.'urisd iation..outside of"San,Joa into'.` <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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />