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SA N d 0 AQ U I N Environmental Health Department <br /> COUNTY-- -- <br /> -.1r„r yi.'W% hr,r <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 /> 1. To..be com letetdl& ' 6 RLi <br /> Business Name &LLr -j-\ Lic.Plate# <br /> owner/Operator Name t �! <br /> Business Mailing Address I mo"Y l �- <br /> City mav\� E't'tt_State C Zip 3" Bus. Ph. 3 <br /> �S Aft. Ph. <br /> t hereby state that the above information is current.true and correct to <br /> toe best of my knowledge and agree to utilize my approved commissary in accordance <br /> with <br /> California iisHe�tt� <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. <br /> commissary is discontinued,the permit holder must notify-the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. I f <br /> Date <br /> Signature„ <br /> Commissary Name_L " <br /> FA# <br /> Bus. Phone <br /> Address <br /> City Zip Owner/Operator -- <br /> Check all appropriate services provided: <br /> Wastewater disposal <br /> [] 3-compartment sink Electrical hook-ups <br /> Solid waste disposal ❑ Food preparation Toilet and handwashing <br /> O Hot& Cold water for cleaning ❑ Store refrigerated food <br /> t�Potable water <br /> p Store dry food/supplies Overnight parking CW(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 canC40) <br /> elled. the <br /> commissary ow hall no ' EHD Immediately. Qate4 <br /> Signature __ _�-_//// I r <br /> 'Joaquin,Co. <br /> 3. To< .eom. I' <br /> The commissary is boated in County. The above food facility meets the <br /> ty Code. The above checked services are available at the <br /> commissary requirements in California Health & Safe <br /> above commissary. Please notify EHD If the status of their operating permit changes. <br /> REHS Signature Data <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 ww,w.sjgov.orglehd <br /> 1✓ AA Ass <br />