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SANAOAQUIN Environmental Health Department <br />.moat <br />COMMISSARY AGREEMENT <br />Mobile Food Facility + Caterer <br />Complete sections ` and 2, If your commissary is located outside of Sen Joaquin County also complete section 9. <br />Business <br />Owner/Operator <br />Rusin sin s Malling <br />Cit Llt Qs <br />Plate <br />x <br />l,_ . hereb,, state that the above information Is current, true and correct to <br />the best of my knowledge and agree rc utilize my ipl.roved commissary in accordance with California Health & <br />Safety Code, and Sen Joaquin Counry 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 re ult in permit <br />revocation and pen mes <br />Signature <br />jf'�Wastewater disposal <br />rl solid waste dispossi <br />ET'H�ot & Cold water for cleaning <br />Store dry foodisupplies <br />compartment sink <br />t_d�Food preparation <br />Z➢ Store refrigerated food <br />P_`:�_Vernight parking <br />ectrlcal hook=ups <br />M�Tollet and handwashing <br />M-gctabl water <br />Vwash <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 facili,v <br />operator fails t mply with tris conditions of thia agreement, or if this agreement is modifiedr canceiled, the <br />commissary o er OAII no* the E-kiD imm� f <br />ediateiy _ j t <br />The commissary is located in _ - County. The above food facility meets the <br />commissary requirements in California Health & Safety ;ode. The above checked services are available at the <br />above commissery.. Please notify EHD if the status of their operating permit changes: <br />REHS Signature.., <br />1868 E. Hazelton Avenue i Stockton. Caiiforn a 9:3``5 z T 209 468.3420 i F 2091464-01 wwvv.sjgov orgrehd <br />