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SAN OAQUIN Envkonmenta6 Health Department <br /> T , <br /> COMMWARY 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.Td be carii Belted by APPLICANT <br /> Business NameTLW (d( 3dSOl0 5 0An (: U&esc-P— Uo, Lic. Plate# <br /> Owner/Operator Name S IL-b: <So� <br /> Business Mailing Addresaq 9-I <br /> State Cfi--Zip gS2�G. Bus. Ph. -lay 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 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. G <br /> Signature ? Date <br /> Toa be E©rrt leted COMMISSARY OWNER/OPERATOR <br /> Commissary Name � e, do ✓!cam i • `t t FA# <br /> Address 2�� •� �� u /i Bus. Phone 90 1 G%. — f (L <br /> City ( ( Zip S Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal W 3-compartment sink 0 Electrical hook-ups <br /> Solid waste disposal 15 Food preparation R Toilet and htihdWasning <br /> 7$ Hot& Cold water for cleaning Store refrigerated food �—x Potable water <br /> Yi Store dry food/supplies / Overnight parking Vehicle wash <br /> I, � S _ z Qalf-r hereby state that the information I have provided is current,true and <br /> correct to the besf of my knowledge,and meets the California Health &Safety Code requirements: If the foot)facility <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall not' the EHD im diately. <br /> Signature Date <br /> 33Qbe coal .feted b the ENV HEAL'TRjurisdtction_outside of San_Joa <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 T 209 468-3420 1 F 209 464-0138 vvww.sjgov.org/ehd <br />