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SAWAAQUIN Environmental Health Department <br /> --COU h T Y---- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility a Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1 1 be coifi� letx�"PPLJCx <br /> Business Name 1 Lic. Plate# � b <br /> Owner/Operator Name N1Avlfl <br /> ///� c� <br /> Business Mailing Address ho:, l � (�- bOc — <br /> City&k( )VI-6--�State Zip qa$38us. Ph - 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 Environm,pRt9T Health Department (EHD) requirements. If the use of the <br /> commissary is dis Hued,the permit hold u fy the EHD. Failure to notify this office ma result in permit <br /> revocation ^ � I <br /> Signat Date �v{ <br /> �.yTo�eX��1?et�ecl�`, >`�� . 551�RY,,Q��EOP�#�A�•QR�k� _> ; ��, `��� ,;�� <br /> Commissary Nam (/\ S FA# (� <br /> Address (x i Bus. Phone �ql 2 I <br /> City Zipq 9-2&_Owner/Operator -S0 S <br /> Check all appropriate services provideed:� <br /> �stewater disposal c��ompartment sink 16 Electrical hook-ups <br /> olid waste disposal C3 FoFo d preparation 0"Toilet and handwashing <br /> U'Hot & Cold water for cleaning H Store.refrigerated food otable water <br /> or dry fo /s4kn <br /> vernight parking icle wash <br /> ereby state that the information I have provided is current, true and <br /> correct to the best ofdge, and meets the California Health&Safety Code requirements. If the food facility <br /> operator fail to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissa o-inn hall notify he EHD im diately. {� n � <br /> Signature Date ' j I /� <br /> '� Tq�fe�gra �fi��ed `,°Et�'�:C��..t� 1-y�'�l'�F'�►s��ta.�',�-��"ts4t�C�� �rid..����tX'�t3.M <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 />