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SAN JOAQUIN <br /> <br />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 />To be completed by APPLICANT <br />Business Name 0 A.)...L.a Lic. Plate # <br />Owner/Operator Name C1)/412L,- <br />Business Mailing Address 301-1 7 et L01211,A-, 6174,2- ° <br />StateetZip c dc-- Bus. ph,,A70- 6.-7e-s-9a' Alt. Ph. <br /> , 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 />+\) <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name FA# <br /> Bus. Phcne 7z) , <br />citycs244M, Zip 9/ 3— Owner/Operator o‘C L'24.4e7 <br />Check all appropriate services provided: <br />fl Wastewater disposal <br />All Solid waste disposal <br />Dir Hot & Cold water for cleaning <br />Store dry foo9upplies <br />, _0921/e.i2- --t12}vil4n <br />correct to the best of my knowle <br />operator fails to comply with the <br />commissary qr shall notify t <br />Signature ,ce-7-2444e-e <br /> <br />Date <br /> <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <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( Stockton, California 95205 T 209 468-3420 F 209 464-0138 www.sjgov.orciehcl <br />City4r- <br />Signature ,N. Date (}1 ti( /9 <br />Address <br />and meets the California Health & Safety Code requirements. If the food facility <br />/ditions of this agreement, or if this agreement is modified or cancelled, the <br />EHD immediatoiy. <br />a 3-compartment sink <br /> <br />O Electrical hook-ups <br />Food preparation <br /> Cr Toilet and handwashing <br />Store refrigerated food <br /> gi Potable water <br />Overnight parking Vehicle wash <br />, hereby state that the information I have provided is current, true and