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SAN <br /> ' OAHH | N <br /> Environmental Health Department <br /> --C[}U NTY—' <br /> Gr:vmo* 9'nw, hc,o� <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + caterer <br /> Complete sections / and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1 . To be completed by APPLICANT <br /> 1, 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 iadiscontinued, the permit holder must notify the EHO. Failure honotify this office may result inpermit <br /> renat <br /> Signature_ Date <br /> 12. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 14 FA# <br /> Address Bus. Phone aI P1 Yk 4 -70 <br /> City zip L?610 O' wner/Operator <br /> Check all appropriate services provided: <br /> �� m6 <br /> ED Wastewater disposal ^= 3-compartment sink �� Electrical hook-ups <br /> t Solid waste disposal [3 Food preparation t Toilet and handvvouhing <br /> mmm� �� <br /> Hot & Cold vvaterfor deaning [3 Store refrigerated food sm Potable water <br /> [3 =/sup9lies <br /> – �� Overnight parking »� Vehicle wash <br /> 1, /-')FPVfAAdiE 7 , 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 ditions of this agreement, or if this agreement is modified or cancelled, the <br /> commis a no <br /> ,!ti EHD immedi tely. <br /> Signature a Date <br /> � 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin,.Co- <br /> Tho commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checked uarvivao are available at the <br /> above commissary. Please notify EHOifthe status oftheir operating permit changes. <br /> REFIS Signature Dat <br /> 1O88E. Hazelton Avenue I Stockton, California 852U51 T 209468'34201 F 209 464-0138 1vmww.sigovurg/ehd <br />