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Kd <br /> Hw- <br /> SAN JOAQUIN Environmentai 'i :.).Kh !0i1,))9i=L <br /> -_COUNT`' <br /> COMMISSARY AGREEMEN7 <br /> Mobile Food Facility o, caterer <br /> Complete sections I and 2. If your commissary is located outside of San Joaquin County also complete section 3- <br /> 1. To be completed bV VPLICANT <br /> Business Name X'11' Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Addred <br /> Ci ty S. Ph.1 � At'. Ph. <br /> 11 'X 0/A A�,71zi 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 pen-nit <br /> revocation and penalties- <br /> Signature a, aw —Date—/ <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name,4/1 FA# <br /> Address <br /> Bus. Phone Z] S <br /> City zip 5:�0 S Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal X 3-compartment sink 4 Electrical hook-ups <br /> Solid waste disposal Food preparation X Toilet and handwashing <br /> Hot& Cold water for cleaning Store refrigerated food Potable water <br /> (tor dry food/slies Overnight parking Vehicle wash <br /> hereby state that the information I have provided is current,true and <br /> correct to the b V it of my knowledge /9nd meets the California Health&Safety Code requirements. If the food facility <br /> operator fail to omply with the ditions of this agreement, or if this agreement is modified or cancelled, the <br /> 1 t I <br /> commissa ow _r shall notify EHD imm e 7ay <br /> o' <br /> Signature z, k, _Date <br /> 13. To be completed by the ENV HEALTHjurisdiction outside a San JoaqU.in0_'0. <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 COMMiSS2ry. Please notify EHD if the status of their operating permit changes. <br /> RENS Signature- Date <br /> 1868 E. Hazelton Avenue 1, Stockton, California e52057 220-9 468--3420 1 1-7 209 464-0138 1 vN,.rftj.sjgGV_orQ1e1d <br />