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' <br /> � � � U � & W � � Environmental <br /> t�U �� U�� Department <br /> ��� [N ��Ut��� � |� u-K���U�������=". ou���"~"" <br /> � ~,^�" "�� ~."""f= . ^ , <br /> `' —COUNTY--' <br /> / <br /> ' Greotneo grows here, <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + caterer <br /> Complete sections Yand 2If your commissaty islocated outside of San Joaquin County also complete section 3. <br /> IA_T6060-0hp 4117,111 <br /> WWAYAPPLI <br /> Owner/Operator Name Q\(-A <br /> Business Mailing Address <br /> ' (5- <br /> jCk\0(�(j\ -,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 discon!ivad, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and <br /> Signature —Date <br /> COMMIS$-AR <br /> Connnni Na \-V`( <br /> Address tA157 ue. Phon <br /> Cici vvner/Operato LWwIER <br /> Check all appropriate services provided: <br /> � <br /> �� <br /> 14 Wastewater disposal IRC 3-compartment sink Electrical hook-ups <br /> Solid na� Foudpreparation �w'Toilet and handvvashing <br /> _- � <br /> Hot & Cold water for cleaning Stone refrigerated food ;!(Potable water <br /> Store dryfood/supp|ies E3 Overnight parking Vehicle wash <br /> |. CA'S C hereby state that the information | have provided iocurrent, true and <br /> correct tothe best ofmyknowledge, and meets the California Hea|th&Safety Code requirements. |fthe food facility <br /> operatorf this agreement, if thist i modified cancelled, the <br /> commissary owner all otify the EVfDlmmediately. <br /> Signature <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 atthe <br /> above commissary. Please notify EHDifthe status oftheir operating permit changes. <br /> REHS Signature Oat <br /> 188OE. Hazelton Avenue I Stockton, California 9S2O51 T 209488-34201 F 209 464-0138 1vmxwv.ejgov.org/ehd <br /> � <br />