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SAN�JOAQUIN Environmental Health Department <br />!' —COU NTY— <br />Greatness graws hero. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility s Caterer <br />Corpplete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Business Name Sv ti✓// �c��� Lic. Plate # <br />Owher/Operator Name�T� <br />Business Mailing Address <br />City ST �K/D� StateZip 'U5 -Ib Bus. Ph. Z�cI Alt. Ph. <br />the;best of my knowledge and agree to <br />Safety Code, and San Joaquin County <br />commissary is discontinued, the permit <br />revocation and pens. <br />Signatu <br />Commissary <br />_, hereby state that the above information is current, true and correct to <br />utilize my approved commissary in accordance with California Health <br />Environmental Health Department (EHD) requirements. If the use of the <br />holder must notify the EHD. Failure to notify this office may result in permit <br />0 <br />Check all appropriate services provided: <br />13 <br />Wastewater disposal <br />Q 3 -compartment sink <br />Solid waste disposal <br />II Food preparation <br />II <br />Hot & Cold water for cleaning <br />IA -,Store refrigerated food <br />E3 <br />Store dry food/supplies <br />Wavernight parking <br />'hone `a.>q^ C(kAv,- !� <br />o rr N <br />0 <br />EpkElectrical hook-ups 0 <br />0 <br />21"foilet and handwashing O <br />II Potable water Z <br />[3Vehicle wash n <br />D <br />hereby state that the information I have provided is current, true and ((0 <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility" <br />CD <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 EHD immediately. <br />Sigriature Ica Date <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 />REFS 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 />A0 <br />i <br />NZ <br />m <br />go <br />Zn <br />mM <br />;U 0 <br /><X <br />M m <br />