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^ <br /> r - ' c� ~ AN ~ AUUN Environmental HeaUtnDepartment <br /> --'CDUNTY-- <br /> ` <�rootoeo 9,oW� here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + caterer <br /> Complete sections I and 2. ff your commissary is located outside of San Joaquin County also complete section 3. <br /> Business Name & <br /> Owner/Operob)rNoN <br /> BusiDnasK8oi|ingAddnas <br /> Bus. Ph. Alt. Ph. <br /> | hereby state that the above information iscurrent,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 discontinued, the per it holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> � <br /> Signature Date <br /> Commissary Name FA# <br /> Check all appropriate services provided: <br /> % Wastewater disposal W3-compartmentsinkElectrical hook-ups <br /> M-8o|idwaste disposal 14 Food preparation M Toilet and handwashing <br /> � <br /> �� �1ot & Cold vvaterfor cleaning �� Store refrigerated food MPotable water <br /> 1~�tored food/supplies Overnight parking 1111Vehicle wash <br /> |. <br /> hereby state that the information | have provided iocurrent, true and <br /> correct to th�best�f 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 owner shall notify the EHDimmediately. <br /> Signature Date I A <br /> The commissary inlocated 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 Dot <br /> 1D60E. Hazelton Avenue i Stockton, California S52U51 T 208468'34201 F 209 464-0138 1ww*'.sjgov.nrg/ehd <br /> � <br />