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SAN J O A Q U I N Environmental Health Department <br /> L --COUNTY-----._ <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 Name Lon l( ��I InCI Lic. Plate# �pq � 09 <br /> Owner/Operator Name N12 12 y By I ` V ff Py V <br /> Business Mailing Address �I O AlVl 001 II A <br /> City ii1�.{1��'q� /� / State�I Zips Bus. Ph. Alt. Ph. <br /> I,Mcl f I�o P 0 L �0�(1 d I I„t hereby state that the above information is current,true and correct to <br /> the best of my knowledge and agree 4 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 o ice may result in permit <br /> revocati d nalties. 1 ' <br /> Signature \ � c,� Date <br /> o he com leted by COMMISSARY OWNER/OPERATORr <br /> Commissary Name � C �I� �'1 �� ��� FA# <br /> Addreerss_- /60 S CM if �P 1� �� Bus. Phone 1311 114 <br /> City ,.11�VI<I O� Zip Owner/Operator !'�' <br /> Check all appropriate services provid�/3/compartment <br /> [g/astewater disposal <br /> sink 0 E ectrical hook-ups <br /> lid waste disposal preparation Get T filet and handwashing <br /> GY Hot & Cold water for cleaning �?Overnight <br /> ore refrigerated food table water <br /> 0 Store dry food/supplies parking Vehicle wash <br /> I, a�(n b l_f,�nI f nI l,° , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge eets the California Health &Safety Code requirements. If the food facility <br /> operator fai comply h t conditions this agreement, or if this agreement is modified or cancelled, the <br /> commissa o er shall n t' the EHD im redia ly. y <br /> Signature Date L <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 /> 1368 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 wmt,/.sjgov.org/ehd <br />