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y.' SAN,4�J0AQUIN Environmental Health Department <br />Ureot`less grows <br />COMMISSARY AGREEMENT <br />Mobile Food Facility * Caterer <br />Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />..,s„1,.f: $. a. #�[i�..E::.1.�-ham 9i'sr d�'3a .$ . ?' / b <br />Business NameCD Lic. Plate # 2; <br />Owner/Operator Name <br />Business M <br />City <br />Ph. Z Alt. Ph <br />11 U 1 1 6lk , hereby state that the above information is current, true and correct to <br />the b t 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 pe (ties. I (� <br />Signature44A6Z - <br />Date s ! l <br />5 <br />`Y <br />Commissary NameLq I i %t n 1 � o L� v t'l W# <br />Addres Q r ( G , Bus. Phone q- I <br />City Zip �J Owner/Operator S <br />Check all appropriate services provided:/ <br />Wastewater disposal Ei'3- ompartment sink Q Electrical hook-ups <br />d waste disposal Food preparation C filet and handwashing <br />Hot & Cold water for cleaning ❑ ore refrigerated food Q P able water <br />9 a er <br />❑ Store dry food/supplies(n C�j✓ernight parking Vehicle wash <br />1,`Ytereby state that the information I have provided is current, true and <br />correct the best of my kno edge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissar owner shall n ify the E immediately c <br />Signature Date (� <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 <br />1868 E. Hazelton Avenue I Stockton. California 95205 T 209 468-3420 F 209 464-0138 1 %,.,,,v',v.sjgov.org/ehd <br />