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SAN4JOAQUIN Environmental Health Department <br /> * . = COUNTY <br /> Greatness grows ,here. <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 4Lic. Plate# _72y:�e�79571 <br /> Owner/Operator Name t <br /> Business Mailing Address 4? ' T, <br /> Cit y1V,4,,11e6 � State(f kZip 7 Bus. PFI 6-,W--4_538AIt. Ph. oZ�'1, ,/�yc� C �l �� , 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 , «C �'�� ���'� Date L C� <br /> Commissary Name f`�z�t 'v c- 2 � <br /> Address / �< Bus. Phone6 <br /> City �� Zip 9,-7 © Owner/Operator <br /> Check all appropriate services provide�d,:_ <br /> astewater disposal �-�compartment sink ectrical hook-ups <br /> olid waste disposal d- ocod preparation oil/et and handwashing <br /> W910—ti, Cold water for cleaning �;Zernright <br /> frigerated food Cd�Potable ater <br /> e dry foo /suppl s parking ehicle wash <br /> 1 <br /> I, z ry 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 omply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary o n ashII noti the immediately. ,�j <br /> Signature ' Date 'T / <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 />