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SANsJOANIN <br /> Environmental Health Department <br /> € `� —COUNTY— <br /> r`qr Greatness grows Fere. <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 /> Business NameLic. Plate# (i � <br /> Owner/Operator Name , v C <br /> Busin s M`nai' Address ` <br /> City 1 I Cd StateftZip Cb B19. Ph. Alt. Ph. <br /> 1, , hereby state that the above information is current,true and correct to <br /> the best of my knowledge an agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and Sa aqui County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is disco 1 d, it holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penal 'e . n � <br /> Signature Date C <br /> i <br /> Commissary Name l <br /> Addre <br /> iAb i n' l Bus. Phone 2� <br /> CityZip��Owner/Operator <br /> Check all appropriate services provided: <br /> 0 Z tewater disposal C�3-compartment sink lectrical hook-ups <br /> Solid waste disposal _ Flood preparation Toilet and handwashing <br /> io Cold water for cleaning 12.1 refrigerated food DAF o ble water <br /> ME d foo suppli s Overnight parking ehicle wash <br /> 1 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 com ly with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary oly r�r�a11 nc�t'ify the HD immediatellyyJg/ � <br /> Signature /J/ A /Ag,fyY::O Date <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 commissary. Please notify EHD if the status of their operating permit changes. <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton. California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />