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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 /> 1 . To be completed by APPLICANT <br /> Business Name; T 1 l 111S r X11 t C- EIU�'c Lic. Plate# Y/1 A45-33F <br /> Owner/Operator Nanle_ i,t H >tir IL���)� [ uT-I E 6RE 2 <br /> Business i1,-lailing ,Address 2 D-� <br /> City State 0, Zip ` 5 7� Bus. Ph. s77 - Llg� Alt. Ph. <br /> 1, �_FU f� lti Irl jCE , _&,UTl6,Q62 . 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 v/ith 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 /> Sionatur_. Date 9/a� z <br /> To.be Completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name u'�,)(D lUl Cry /c�klfL�C ZCc/t Z/1 FA- <br /> Address l r�/ tllti'l��� S ! Bus. Phone <br /> City �c1� (+✓'/v, Cit Zip `(Sy Owner/Operator <br /> oCheck all appropriate services provided: <br /> tx-�/Vastev,,aiter disposal /3-compartment sink ''l/Electrical hook-ups <br /> L,/Solld -aste disposal /Food preparation i✓l oilet and handwashing <br /> ��� ,:'e refrig rated food !/potable Nater <br /> io: & ,ol,a r�,a er ror c caning ,?� 9 <br /> tore dry food supplies ✓ ,. :might parking /ehicle wash <br /> hereby state that the information I have provided is current, true and <br /> correct to the best of my knosrtedge, 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 o+wne .shall notify the EHD 'xlmediately. Zz C) <br /> Signature <br /> 3. To be com leted b the ENV I�EA�TI-1 �irisdiction outside of San Joaquin Co. <br /> County. The above food facility meets the <br /> The commissary is located in <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 /> Date <br /> REHS Signature <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 />