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SANS>JOAQUIN Environmental Health Department <br />—COUNTY— <br />Greotness grows here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />11. To be completed by APPLICANT I <br />Business <br />Owner/Operator <br />Business Mailing <br />Plate <br />Ph. <br />I, , hereby state that the above information is current, true and correct to <br />the b6sT0 my knowled a and agree to utilize my approved commissary in accordance with California Health & <br />Safety Code, and Sanloaquin 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_PeAalties-% <br />Signature`—""^----�- Date�� <br />12. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name FA# <br />rere <br />City <br />Check all appropriate services provided: <br />Wastewater disposal O 3 -compartment sink 9F Electrical hook-ups <br />Solid waste disposal E3 Food preparation qt Toilet and handwashing <br />W Hot & Cold water for cleaning 13 Store refrigerated food W Potable water <br />E3 Store dry food/supplies JO Overnight parking IF Vehicle wash <br />I, Ord e A ZIV262 ? _ , hereby state that the information I have provided is current, true and <br />correct to the best of myXnowledge, 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 shalLpotify thea EHD)��r ediately.. <br />Sig <br />13. To be completed by the(LIfQV HEALTH Jurisdiction outside of San Joaquin Co. 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 />