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Environmental Health Department <br /> --COUNTY— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 0 caterer <br /> Complete sections I and 2. if your commissary is located outside of San Joaquin County also complete section 3 <br /> 1. To bocorn plet6d bY APPLICANT' <br /> Business Name 02'711A,��tzv <br /> 1,4 <br /> Lic.Plate# 4111,5 7 ez <br /> y <br /> OwnerlOperator Name <br /> Business Mailing Address 4kR11 <br /> Cmf a4g— State�Zip-2LIv /Bus. Ph.A - t. 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 Count' Environmental Health Department (END) requirements. If the use of the <br /> commissary is discontinued,the p it holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. L7 - 'j'9'0-j eq <br /> Signature af1712C,211 'C)-)"(f Y'CDate <br /> , — - <br /> F2—. To be completed by ICOMMISSARY OWNER/OPERATOR <br /> Commissary Name/1 /4 t FA# <br /> Addressc:-.2�W �' Bus. Phone "W'4r-�.5'-zo <br /> City .c zip r/C-� "OvitnerlOpsrator All, <br /> Check all appropriate services provided: <br /> Wastewater disposal 0( 3-compartment sink V. Electrical hook-ups <br /> Solid waste disposal Food preparation Toilet and handwashing <br /> Z5-[4 Hot& Cold water for cleaning F Store refrigerated food -Y Potable water <br /> jfore dry food/supplies Overnight parking Vehicle wash <br /> I (d27/ hereby state that the information I have provided is current,true and <br /> _ IV4111f — <br /> c(Yr-rect,to the best of my knowledge,and meets the California Health&Safety Code requirements. Ilthe food facility <br /> operator fails io 00 mplythe End tions of this agreement, or if this agreement is modified or cancelled, the <br /> ' v"' <br /> ith <br /> commissa er shall notify EHD immeAiately. <br /> Signature <br /> Date <br /> 13. To be completed by the ENV HEALTH jurisdiction-outs.ide of.-San.JQaquin Co. <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 /> RENS Signature Date <br /> 1866 E. Hazelton Avenue I Stockton, California 9520 1 7 209 468-3420 I F 209 46?-0138 1 <br />