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SAN.-IOAOUiN Environmental Health Department <br />COUNTY <br />COMMISSARY AGREEMENT <br />Mobile Food Facility + Caterer <br />Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1. To <br />Business <br />Owner/Operator <br />'1007 <br />Business Mailing Address 33 , . G ly>4` <br />City/pC711Pj— Stateeff Zip`5da7 Bus. <br />I, A Vas�4 e 7' 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 disconti , the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation arena ' . / <br />-/—'570.2-� <br />12. To be completed. by COMMISSARY OWNERIOPERATOR - I <br />Commissary Name LA FA# <br />Check all appropriate services provided <br />E 3 -compartment sink <br />Wastewater disposal <br />/olid waste disposal <br />Hot & Cold water for cleaning <br />0 Food preparation <br />® Store refrigerated food <br />EI 'cal hook-ups <br />T "let and handwashing <br />ble water <br />M / tore dry food/l��+ppIies Overnight parking VehiGa wash <br />I, l , ���/� / 2W1Vpt 4- — , hereby state that the information I have provided is current, true and <br />cored to the best of my knowledge, and eets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply with the co ons of this agreement, or if this agreement is modified or cancelled, the <br />commissaryr shall notify the16 PH <br />immediatei <br />Cinnninro �.f��2 Date /e� e2 _R I;? - <br />13. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <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 <br />1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />