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SAN, MOWN Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food FacilityC,aterer <br /> Complete sections 1 and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. TO becorjn�Pleted bq APPLICANT ' <br /> Business Name 1�7T)SS A I )R_> SY1q­GFv <br /> —S Lic.Plate# <br /> Owner/Operator Name <br /> Business Maili g Address G <br /> City-Mf3 -State Zip �us. Ph 2 Aft. Ph.?�� <br /> I, hereby state that the above infomration is current,true and correct to <br /> the best of my knowledge and agree to utilize my approved commissary in accordance with Cafffomia 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 resu t in permit <br /> revocation a Eti <br /> Signature Date <br /> 2 COMIIi SARY;04Cr'N€Rt?PELQR <br /> Commissary Nam �/l h <br /> Address �J r f11(! Bus. Phone 2 <br /> Citys ( Zip Owner/Operator VU r� <br /> Che k aft appropriate services provided: <br /> 7 <br /> "lid <br /> disposal s�'3 compartment sink �lechicai hook-ups <br /> � lid waste disposal Food preparation B�Toilet and handwashfng <br /> CKAot& Cold water for cleaning ❑ St e refrigerated food Potable water <br /> • Store dry food/supplies � Overnight parking U,'Ve-hicle 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 ly with the conditions of this agreement, o if this agreement is mofii ed a cancelled, the <br /> commissaryo otify HD' ediately. <br /> Signature 'E '/u �� � Date �v <br /> 3y To beotii leted btke E#�kV I#EALTH 'urisdetroRr.r�rtfsiiie of San .Iqa` uti� Go : <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?venue I Stockton. California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org; <br />