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SANJOAQUIN Environmental Health Department <br />C 0 U N TY --— <br />COMMISSARY <br />Y-- — <br />COMMISSAR'S 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 />,":Ctc.,'N.Y �_F r ! r' �' t m � <br />1._'To becreed' A��?L1C�ANT�, rtR���, <br />t ' l�K * _ ! �,• <br />"2 Business Name'l PT( , ice,. ,4 f Lic. Plate # - ��� <br />Owner/Operator Name <br />Business Mailing Address <br />City ;,State Zip Bus. Ph." �LC 01 t i' tr), It. Ph. <br />I,<�E/p hereby state that the above information is current, true and correct to <br />the best kr my know e'd`ge and agree to utilize my approved commissary in accordance with Califomia 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,, Date14 <br />" <br />i <br />! <br />Commissary Name ', i! \ SPH (, '' hl;P <br />Address Bus. Phone <br />Citr I6r Zip �i�r' �' �� Owner/Operator •� EL : Fr <br />Check all appropriate services provided: <br />CNastewater disposal 0- 3 compartment sink EF Electrical hook-ups <br />Solid waste disposal 12 , ood preparation i �7.0,�--het and handwashing <br />`lot &Cold water for cleaning 0�Store refrigerated food l�Potable water <br />tStore dry fopd/suppl',es ,U10-vernight parking E34ehicle wash <br />Y11 .i Ki9 , 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�0 co ply with the condi ' ns of this agreement, or if this agreement is modified or cancelled, the <br />commissar owner hall noti the EHF1 immediately. <br />Signature r �?� Jlr ��� �,! .! 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 />Date <br />363 E. Hazelton Avenue I Stockton: California 95245 ' T 249 488.3420 <br />� F 249 464-4138 1 <br />