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SQ N_,)OAQ N 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 /> Business Name n M C1-)nacohn Lic. Plate#��( ) <br /> Owner/Operator Name hY-� a`CC-2 6 n-zn ll 7 <br /> Business Mailing Address y2' o 6n ft� <br /> City 1,0 tateCeLZirrjja5a Bus. Ph. Alt. Ph. <br /> I, 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 discontinue ermit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penal ' y <br /> Signature Date l j ^ 2a ZZ <br /> Commissary Name 'ammo`v5'- lv _FA# <br /> Address Bus. Phone �� � 2- 8� y <br /> City _e,6 Pi' Zip &157-ye) Owner/Operator <br /> .Check all appropriate services provided: �� <br /> MVllastewater disposal ®'3-compartment sink �®'Electrical hook-ups <br /> Solid waste disposal Food preparation ®'Toilet and handwashing <br /> M/ <br /> 4 & Cold water for cleaning tore refrigerated food M/Potable water <br /> dry food/supplies 13'Overnight parking Vehicle wash <br /> hereby state that the information I have provided is current, true and <br /> correct 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 shall notify the EHD immediately. <br /> Signature e "� Date <br /> WINFIffil <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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />