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S8N=W U A H U | N <br /> Environmental Health Department <br /> COUNTY----- <br /> r e o.1 n e s s <br /> C}UNTY-- <br /> /eo�npo ro~s 6e,� <br /> COMMISSARYAGREEMENT <br /> Mobile Food Facility + caterer - <br /> Complete sections Yand 2 If your commissary is located outside of San Joaquin County also complete section 3. <br /> Business � <br /> Name J.A_(0(-> I I )-t <br /> Owner/Operator Name <br /> Business Mailing Address <br /> ate Zip Bus. Ph 0 6.41t. Ph. <br /> Stat _Z <br /> C ty ' 7 hereby state that the above information is current,true and correct to <br /> I� est Wmykn4owe ge and�agreeipto utili;e my approved commissary in accordance with California Health & <br /> t e Ab <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 result in permit <br /> revocation and penalties. <br /> Sig notu _-� m <br /> i <br /> Commissary Name <br /> Address <br /> Cit Zip Owner/Operator L�/,A I 10A�A <br /> Check all appropriate services provided: <br /> — <br /> 11,,Wastewater disposal Iff"3-compartment sink Gle"Electrical hook-ups <br /> ="'SoUdwaste disposal dpnaporation 0-���|etand handvvanhing <br /> ' ~_~�� <br /> & Cold vvo�rfor cleaning �� Szore refrigerated food El—rotaU\evvoter <br /> � ~~~~�'ernight parking nYI�ehic|mvvamh <br /> hereby�atethat the information | have provided iacurrent,true and <br /> ' de.�_nd'meetathe California Health&Safety Code requirements. |fthe food facility <br /> correct to the y le <br /> ' unns <br /> opera or f tc co ply with the con� of this t or if this t is modified or cancelled, the <br /> commissary,,c1nel. hall notti the EHG immediately. <br /> ff <br /> Signature Itl JOAX' A� Date <br /> The commissary is located in County. The abovefood facility meets the <br /> commissary requirements in California Health & Safety Code, The above checked oen/ioea are available at the <br /> above commissary. Please notify EHDifthe status oftheir operating permit changes. <br /> REHS Signature Oe <br /> �8G8E. Hazelton Avenue I Stockton, Ca|hbmia95205 | T 209468'3420 { F 2O8464-0138 \ vpxw.sjgovorg/ehd <br /> / <br />