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SANDIOAQUIN Environmental Health Department <br /> s Y ` ---C-OUNTY— <br /> Great`nessgcovs .here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility I& Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> Business Name t2, Lic. Plate# 01Sli <br /> Owner/Operator Name �L <br /> It <br /> Busine s Maili Address <br /> City StatLZip 1S11T Bus. Ph. Q 8 / �Li Alt. Ph. <br /> 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 /> revocationd enalties. �] <br /> Signatureck� / Date <br /> be ';t rrr feted i�Wl- Sr$A_R;M O(D Y CAROB AT f2< A <br /> Commissary Nam 41 A# ( 1 <br /> Add re Bus. Phone 1 l L <br /> City Zip 0'516S Owner/Operators Y <br /> Check all appropriate services provided: <br /> wastewater disposal compartment sink Q'Erectrical hook-ups <br /> ff-S"o—fid waste disposal 0-F-ood preparation EToilet and handwashing <br /> Cl �ot& Cold water for cleaning 1r'gtore refrigerated food E -Potable water <br /> tore dry food/supplies Overnight parking ehicle wash <br /> I, , hereby state that the information I have provided is current,true and <br /> correct to thi;bldsi of my knowledge, and meets 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 /> commissary oFvner shVI notify the EHD irytryiediately. <br /> Signature I\ II ��, A� 6(/%AQLyf/� Date <br /> 3:_To e �;tit tele;_, ��e tUNEY�L�f'lll��;„, r�s�rctton�o fisrcie � Sa t;��np . <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 />