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SAN J OA Q U I N Environmental Health Department <br /> —COUNTY-- <br /> w,rea cess jcrows ,:el e. <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 50 U CS a V� lLe— Lic. Plate# <br /> Owner/Operator Name (C C T1 <br /> Businesf, Mailin Address <br /> Cit StateCLZip I�Z Bus. Ph.Wy 26�3 q Alt. Ph. <br /> Plug , 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 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 office may result in permit <br /> revocation and penalties. <br /> Signature �� Date <br /> lam <br /> Commissary NamY t1 l �W. a—WOTS A# <br /> Add re s �D� 77 <br /> ' 1� Bus. Phone � 6 �� <br /> city (/ b ) 1 Zip 'J?D 1) Owner/Operator &n rn <br /> Check all appropriate services provide_d� <br /> p/W stewater disposal B 3-compartment sink lectrical hook-ups <br /> i�S lid waste disposal L7 Food preparation 0 Toilet and handwashing <br /> t & Cold water for cleaning (/St re refrigerated food 0-1Potable water <br /> GAS/tore dry food/suppli C ernight parking La'Vehicle wash <br /> I,� ,{�YRAL4ereby state that the information I have provided is current,true and <br /> orrect <br /> cto the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the con 'tions of this agreement, or if this agreement is modified or cancelled, the <br /> commis ary ow ersh^^alAAl n tify the E immediately! <br /> Signatur V Wl4ULM2Date t 1 <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 />