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. t SAN.,JOAOUIN Environmental Health Department <br /> COtJNTY <br /> r <br /> COMMISSARY" AGREEMENT <br /> Mobile Food Facility r Caterer <br /> Complete sections t and 2, if your commissary is located outside of San.Joaquin County also complete section 3. <br /> Business Name h of P 0\ I J CA I II Gi li ic. Plate <br /> Owner/Operator Name A- <br /> Busies Mailing Address e _ o hhe. <br /> City f ll StatEU Zip J?+ Bus. Ph. ZS STV! JV Alt. Ph. <br /> 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 Callfomia Health & <br /> Safety Code, and Sa 'Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is hued,the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation an pe kiss. <br /> Signature <br /> �nsr d <br /> Y OWN <br /> CommissaryNam v <br /> Address Yll Bus. Phone <br /> City L ZiprawnerlrJperaior V� ` v <br /> C all appropriate services provided:: <br /> Wastewater disposal 112 3-compartment sink electrical hook-ups <br /> 1/solid waste disposal Q"Fd preparation �To'rlet and handwashing <br /> ®'Hot& Cold water for cleaning O St refrigerated food 2 Potable water <br /> is Store dry food/supplies H Overnight parking D40hicle wash <br /> I, , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,and meets the Cafifornla Health&Safety Code requirements. If the food facility <br /> operator fails to ly with the vriditions of this agresment, o if this agreement is modified or cancelled, the <br /> cSolgmnrnaWisrsaa ry o =othd <br /> Date <br /> L Ai <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 evallable at the <br /> above commissary. Please notify EHD If the status of their operating permit changes: <br /> l2EHS Signature <br /> 1868 E. Hazelton Avenue 1 Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 wwx.sjgov.org.!ehd <br />