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SAN JOAQUIN <br />jS <br />^-2 6 -Date <br />in Co. <br />REHS Signature.Date <br />ww.v s.gov.c'c e~c <br />^Wastewater disposal <br />3/^olid waste disposal <br />-^xnot & Cold water for cleaning <br />ZZk^tore dry food/suppiies <br />Z?^iectrical hook-ups <br />^CoTlet and handwashing <br />Z?^otabie water <br />JZVehicie wash <br /> <br />3, To be completed ft <br />Tne commissary is located in _____________________County. The above food facility meets the <br />commissary requirements in California Health & Safety Code The aoove checked services are available at the <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Environmental Health Department <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3 <br />1. To be completed by <br />Business Name | 6$ <br />Owner/Operator Name <br />Business Mailing Address fl-CUK <br />City Statefp Zip Bus Ph.Alt. Ph. <br />I----------------------------------------------------------hereby state that the above information is current, true and correct to <br />me oest 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 />^ommissary 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 <br />'S68 E. Hazerm-Avenue Srocktcn. California 95205 T 209 458-3420 r 209 464-0'.38 <br />^7X1 rn .0 Lie. Plate# U <br />Commissary Name f FA# <br />Address Bus. Phone <br />City--------D&Zip AZ Owner/Operator <br />Check all appropriate services provided: <br />jXpcompartment sink <br />(□?Food preparation <br />(z^Store refrigerated food <br />22^6vernight parking <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 tne food facility <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or canceiied. the <br />commissary owner shall notify the EHD immediately. <br />Signature.