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SANAMUIN Environmental Health department <br /> �� - . {tis.r:s�tri ti'CS ryrin": Ys i. <br /> •.X COMMISSARY AGREEMENT <br /> Mobile Food Facility • Caterer <br /> Complete sections f and 2, if your commis"#y is located outside of San Joaquin County also complete section 3. <br /> Business Name beDs c. Plate# tJ J `� <br /> Owner/Operator Name I E ` <br /> Busine Maiil g Address <br /> city�Stal R- Bus, Ph. Alt. 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 {eco nued,the per holder must notify the EHD. Failure to notify this office may result in permit <br /> revoeatlon an t r <br /> Signature Dated)1 <br /> Commissary Nam I n ,(A 0 <br /> Address h' �dl Bus. Phone Z <br /> Cit Zip Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal M-1-compartment sink U-Sectrical hook-ups <br /> gf'Solid waste disposal ;370od preparation P'follet and handwashing <br /> 6 Ho & Cold water for cleaning )2-Store refrigerated food t}Potable water <br /> 'O Store dry food/supplies vernight parking 0-"Micle wash <br /> 1, , hereby state that the information I have provided Is current, true and <br /> correct to the test 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 i modified or cancelled, the <br /> Imm <br /> commissary o er II no th D ediatel Q �� <br /> $ignsture Date (/ <br /> The commissary is located in County, The above food facility meats 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 94.205 !, T 209 468-3420 I F 209 464-0138 1 www.sjgov.orglehd <br />