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-� SANAHO N Environmental Health Department <br /> —COUNTY— <br /> r' r <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> �� 'lib be;Cflt71 IGIVU;v QAC=• L V/A7V�_ N; �.Y �A` - YM )z <br /> . . <br /> Business Name Lic. Plate# 42-2Z <br /> Owner/Operator Name (YLA'Z l Vl ZS <br /> Busin(e1 s Mailing Addressoo_ q <br /> City l� �State�Zip"1 2 Bus. PhIV bD 1 Alt. Ph. <br /> I, lWE 01 ✓t$ V wt- hereby state that the above information is current,true and correct to <br /> the best f my knowledge an gree 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� 11�Z I j. �/ Date <br /> 2 Fo,be cotm , ted b COMMISSARY Oltr/�f 4-J-0 RAT(3R ' <br /> Commissary Name <br /> Add r . � `( Yl �y •Bus. Phone <br /> l <br /> City Y <br /> Zip J 2t) Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal _,J; <br /> '3-compartment sink I121�`Electrical hook-ups <br /> Solid waste disposal ErFood preparation Ckroilet and handwashing <br /> t& Cold water for cleaning O�Store refrigerated food U`Potable water <br /> I S e d food suppli s i� Overnight parking � Vehicle wash <br /> .'2Z;: /ir it 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 com ly with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary o r all n fy th HD immediately. <br /> Signature Date <br /> $ `I a be sorra feted b _#he: NU F#EAL H`'ufascCGcficf�_aIA.sie of.San Jo nCa <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 />