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1 0 A n t�i4U 1 I�,f pePaa'tr-r-aea-tt <br /> ly Environmental Health <br /> C"MISSARY AGREEMENT <br /> Mobile Food Facility r` Caterer seclron .3. <br /> CompJQte s©Cti�ns 7 m late <br /> ` T� I] and 2. 1f your commissary is located outside of San Joaquin County also co P <br /> ------e_complete� b ------ <br /> -- _...Y_AP_PLI CANT <br /> tis ness Name Plate# <br /> n <br /> Owner/operatorJ <br /> Name <br /> --- <br /> Business Mailing Address t { 3 <br /> City w I 7. C S�AIt. Ph. <br /> �J StateZip Bus. Ph. correct to <br /> I true and <br /> ------ California Health & <br /> herebystate that the above information is Curren , use of the <br /> the best of my kn to edge and agree a to utilize my approved commissary in acco feq�rements. if the permit <br /> Safely Cone, an S n Joaquin County Environmental Health Department (EHD) this office may result in <br /> commissary is di c ntinued, t e permit holder must notify the END. Failure to notify <br /> revocation an p allies. Z <br /> Signature Date - - <br /> ,4L2. To be_cc)mplet _ COMMISSARY_C3INNERIoptkAT=-- <br /> Commissary Name G _ <br /> Address U us. 1�hone aL - <br /> Check all appropriate seR ices provided- <br /> 0 Wastewater disposal <br /> 0 3-compartment sink t3 Electrical hook-ups <br /> [3 Solid waste disposal E3 Food preparation <br /> 13 Toilet and handwashing <br /> 11 Hot & Cold water for cleaning 0 Store refrigerated food 0 Potable water <br /> E3 Store dry food!-supplies i Overnight parking 0 Vehicle wash <br /> �n , hereby state that the information I have provided is current, true and <br /> carred to the best of 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 sh I notify the D imrn 'ately. <br /> Signature _ `Date _ <br /> To e completed by the 1V LTH 1uriSdiction outSide of San Joaquin Co <br /> The commissary is -rented in California <br /> _ County. The above food facility meets thie <br /> commissary requirements in California Health & Safety Code, -The above checked services are ,3vailabie at Cl3t <br /> above commissary- Please notify EHD if the status of their operating permit changes. <br /> RF-HS Signature_------ - <br /> -------- ate <br /> 1f16 �-. Hazelton Avenue I Stockton, Caiifami.i 95205 <br /> 1 Y 2()9 ass-3a20 1 F 209 41554-013t? <br /> ' � ��b to 1 <br />