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++o�, <br /> SAN: UAQUUN Environmental Department <br /> --[{JUNTY-- <br /> (�/poCnesx qrnnx here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility * CBf8F8[ <br /> Complete sections Yand 2. Ifyour commissary is located outside ofSan Joaquin County also complete section 3. <br /> 1. To' be completed by APPLICANT <br /> 8uein8So Name iC. Plate <br /> Owner/Operator Name. (3EPfflh(\� P��K62_ <br /> Business Mailing Address M'DA <br /> Cit STDCLUN Statej2&zi Bus. Ph(20) �Z Alt. Ph. <br /> MIA 1� k 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 discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date 2,e, 2- 3 <br /> 12. To be completed by COMMISSARY OWNER/OPEMTOR <br /> Commissary <br /> Check all appropriate services provided: <br /> 13 Wastewater disposal E3 3-compartment sink E3 Electrical hook-ups <br /> E3 Solid waste disposal E3 Food preparation E3 Toilet and handvv8ahing <br /> 0 Hot & Cold water for cleaning L3 Store refrigerated food 0 Potable water <br /> E3 Store d 0 Overnightp@rking E3 Vehicle wash <br /> |. henybyatahe 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. {fthe food facility <br /> operator fails to comply with the conditions of this ogreemont, or if this agreement in modified or cancelled, the <br /> oumnoia <br /> Signature Date / / <br /> 3. 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 aen/ineo are available at the <br /> above commissary. Please notify EHOifthe status oftheir operating permit changes. <br /> REHS Signature <br /> 1868 E. Hazelton Avenue | Stockton, California 95205 1 T 2U9468'3420 1 F 209 464-0138 1 wvmm.sjgov.org/ehd <br />