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SAN JOAQUIN <br />—COUNTY— <br />EnvlronmenW Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Complete sections 1 and Z If your commissary is located outside of San Joaquin County also complete section 3. <br />Business <br />Owner/Operator <br />Plate# <br />Business -Mailing <br />� Address 0\4& \ \ t t� <br />city �( C�.' D� Sttate��Zip ) a- Bus. Ph. ' OS-3C� c)Alt. Ph. <br />I, t alyksu f�rwt _ , 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 pertalbes. A j o <br />Commissary <br />Phone ZvGi — 61- 046; <br />- - A <br />Check all appropriate services provided: <br />,V Wastewater disposal 19( 3 -compartment sink W Electrical hook-ups <br />Solid waste disposal IX Food preparation Toilet and handwashing <br />iTY Hot & Cold water for cleaning 10 Store refrigerated food eK Potable water <br />Store dry food/supplies a Overnight parking rx Vehicle wash <br />I,` Q244ei� �i✓'7cc' 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 comply with the conditions of this agreement, or if this agreement is modified or cancelled,' the <br />commissary owner shall notify the EHD immediately. a j <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <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 />r <br />