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rSANADANIN Environmental Health Department <br /> G,rentness grows litre. <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 Nam /�'7- '/0Y l Lic. Plate# _7';rj!�; <br /> Owner/Operator Name_Aro [_ r_- I i U , <br /> Business Mailing Address_ ey <br /> City State CjljZip2W�aBus. Ph� l�6 -4_53_cc2--Alt. <br /> 1, 122X6 C '�-: l i �� '� , 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 �'K OL L��� � "� Date67/ <br /> o) <br /> Commissary Name ���t�v e% �. �7 (2!� <br /> Address r- 4 11 Bus. Phone 416 <br /> City Zip 9, aC Owner/Operator r ° ' <br /> Check all appropriate services provided: <br /> W11-a-stewater disposal -compartment sink ectrical hook-ups <br /> olid waste disposal ood preparation oilet and handwashing <br /> Hot & Cold water for cleaning tore r frigerated food otable water <br /> re dry foo /suppl' s vernight parking �ehiclewash <br /> 1 <br /> I, 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 )sh II noti the immediately. <br /> Signature r 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 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 />