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SANJOAQUIN Environmental Health Department <br /> —:OUNTY-- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections f and Z If your commi <br /> ssary is locate�pd, outside of San Joaquin County also complete section 3. <br /> �,. .. <br /> F. <br /> Business Name Lic. Plate# �an`;N4- <br /> Owner/Operator Name (3 t <br /> Business allin Address if1 <br /> city�Statecm Zip Bus. Ph2KO G 131 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 Co ty Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued,the pe Ider must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. �f /I <br /> Signature \ Date42,1 7i1 f/1 <br /> Commissary N iam I 1,( V� <br /> Address V 4-0 VA Bus. Phhoone "I �1 <br /> CityZip Owner/Operator <br /> Check all appropriate services provided: <br /> M'Wastewater disposal 131-compartment sink EY�Electrical hook-ups <br /> _/Solid waste disposal good preparation P Toilet and handwashing <br /> Of HHot& Cold water for cleaning �Store refrigerated food U Potable water <br /> �r3 Store dry food/supplies 0 Overnight parking f3 Vehicle wash <br /> ^ <br /> I, '�/� , 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 oner sh notify the EHD imme ' tel . <br /> Signature[ //l 14� Q/� Date <br /> V 1 _.vtr v i <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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />