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i SQNJOAQUIN Environmental Health Department 41—COUNTY— . COMMISSARY AGREEMENT Mobile Food Facility + Caterer Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. 11. To be completed by APPLICANT I Owner/Operator Ph. -L-Z-- I, , hereby state that the above information is current, true and correct to the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the commissary is discontinued,, the permit holder must notify the EHD. Failure to notify this office may result in permit revocation and penaltie I . – / _ Commissary Che k all appropriate services provided: Wastewater disposal U -.3 -compartment sink IYlectrical hook-ups g Solid waste disposal Food preparation EiToilet and handwashing CKHot & Cold water for cleaning 1 St re refrigerated food Ua Potable water Store dry food/supplies Overnight parking al/ehic{e wash 1, , hereby state that the information I have provided is current, true and correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility operator fails too6gly with the conditions of this agreement, o if this agreement is modified or cancelled, the commissary a sh�iotify t�H0,06nediately. _` . I , n l,, i 3. Tobe completed by the ENV HEALTH jurisdiction outside of San Joaquin Co., The commissary is located in County. The above food facility meets the commissary requirements in California Health & Safety Code. The above checked services are available at the above commissary. Please notify EHD if the status of their operating permit changes. REHS 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd