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' UEnvironmental Health Department <br /> 4 <br /> COUNTY <br /> Greaviess 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 ����✓ ( , �� � J b Lic. Plate# ` <br /> Owner/Operator Name _bLNI & LD A- . y IU <br /> Busin ss Mailin Address " I t�lJ b t� LO <br /> Cit State Zip 21Z Bus. P ;I Alt. Ph. <br /> I, o �( , 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 /> SignatureDate44 <br /> Commissary Nam WA n UAFA# <br /> Addr S I 1nr�n Bus. Phone <br /> City Zip Owner/Operator V'� �� J�,a ►�' <br /> Che all appropriate services provided: <br /> Wastewater disposal -compartment sink CYElectrical hook-ups <br /> Solid waste disposal ood preparation let and handwashing <br /> L Hot & Cold water for cleaning ❑ Store refrigerated food otable water <br /> tore dry food/supoes _QL-c vernight parking CjV'_e_hicle wash <br /> A�Y hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,and eets 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 /> commissa owne shall n tify the HD immediately I )-3 1 /'7_'D <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 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 />