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SAPJQQIEnvironmental Health Department <br /> --C O U N T Y-- <br /> :s .,"} <br /> 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 Tobe eorit�pletQed by A/k�?PLCCANTC 2 <br /> Li <br /> Business Name �n—t/ Lic. Plate# J <br /> Owner/Operator Name S� 111�AdO\ CQA1, T'OrreS <br /> Busine s Mailing Address b'l C,7 ree <br /> City (✓ y) StateC. _Zip�2D9Bus. Ph. It. Ph. <br /> I, S C& 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 pe Ities. <br /> Signature S U A/U.y" Date 2 <br /> 2. "Eo_be com etedFb TGOTVIMiSS?C�Y 011�/AJERf�Pl��ATOR <br /> Commissary Name �1 <br /> Address Bus. Phone !i <br /> City S �L-t� _cyzipArJDOwner/Operator <br /> Check all appropriate services provided: <br /> wastewater disposal Cd 3 compartment sink II—'Electrical hook-ups <br /> Solid waste disposal ood preparation 12'T—oilet and handwashing <br /> WTH'ot & Cold water for cleaning Cxbtore re rigerated food C7�ota e water <br /> !�te d food suppli s vernight parking ehicle wash <br /> hereby state that the information I have provided is current,true and <br /> correct to the best of my <nowledge, 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 r all,nJgkffY t,,h/e/AHD immediately � <br /> Signature /z // C7cc�r�nn�/lir�> Date <br /> 3, To, be cei n Cetei;bY the`ENV FiALTH " nsti�Etiara ©ttsde a Sand` U Cb `` <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 />