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! r" nom^i S46JOAOUIF♦ Environmental Health Department <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 /> ,p�,\t :ftin"��y�5�'-`5 <br /> Business Name �� L Y ) 1 S Lic. Plate# I ✓� <br /> Owner/OperatorName�T G \ <br /> Business Mail' g Address f 2 <br /> City . State�Zipc��Bus, Pm )SI 6I ID Alt. Ph. <br /> I, y Pi \rl1 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. <br /> Signature /�, � �l. Date 1 2 <br /> ��f��Q�V'�.G �t�,.., .._. .� �Zi��' )Yl�e3,':.c l��i®•fFY�..._.c._a x, - ��s'`ay.P } na �"��2Fy <br /> Commissary NaameY CA <br /> Address U \ b(dl1 Bus. Phone y �— <br /> City L �l Zipq�Owner/Operator r V <br /> Check all appropriate services provided: <br /> stewater disposal Q -compartment sink O—Electrical hook-ups <br /> olid waste disposal CI.F6od preparation oilet and handwashing <br /> �ot & Cold water for cleaning El Store refrigerated food/otable water <br /> ! e d food suppli s �fif_Olvernight parking 04ehicle wash <br /> I, C� azo A ut hereby state that the information I have provided is current, true and <br /> correct to the best of my-knowledge,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 r all n the/AHD immediately <br /> �/ I <br /> Signature /J� �nC7�,,�A��/Lr�J Dater <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 mvw.sjgov.org/eho <br />