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sgpO. �� <br /> �• � SANzI0AQUIN Environmental Health Department <br /> t —coUNTY <br /> es r Greafnesi ;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 Uo Lic. Plate# <br /> i <br /> Owner/Operator Name <br /> Bus`jp s M lAddress <br /> City�State_0nZip us 4 151it- Ph. <br /> I,� OAC( VC r1ifl-L- , hereby state that the above information is current,true and correct to <br /> the best of my knowledg6 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 f YC r Cif C MZ Date <br /> - <br /> �v� <br /> Commissary Nam 4 1 C '- i t Al l � <br /> Addres C Bus. Phone <br /> City Zip 1 Owner/Operator {D <br /> Check all appropriate services provided: <br /> [�V astewater disposal C3 3-compartment sink Ci Electrical hook-ups <br /> Solid waste disposal 0"FFood preparation Toilet and handwashing <br /> Hot & Cold water for cleaning 13 5 e refrigerated food P able water <br /> ® ore d food/supplies Overnight parking Vehicle wash <br /> I, VUJI/I \1/l0/IA7, 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 compl with the conditions of this agreement, or if this agreement is m dified or cancelled, the <br /> commissafry�gAw,ner sh notify the EHD imm lately. r' <br /> Signature 11V11 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 209464-0138 1 www.sjgov.org/ehd <br /> I <br />