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SAN 1OAQUIN Environmental Health Departmeror <br /> 0"U Iii j Y,--..--.- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility z Caterer <br /> Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> T. To be corrj feted:b APPLICANT <br /> Business Name N Lic. Plate# 2.2Z <br /> Owner/Operator Name vie'S <br /> Busin�el s Mailing Address 1� <br /> City l� V'_)Stat 2 1 Bus. Ph.'20 bD 6 Alt. Ph. <br /> I, Zoo 06 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 Date 12 <br /> 2.,i o be coni Ieted b COMMISSARY OWNER,/OPERATOR. <br /> Commissary Name <br /> Addr Coy ' `r(1Y1 (� •Bus. Phone �� y <br /> City (. Zip ZD Owner/Operator _ fbA�A <br /> Check all appropriate services provided: <br /> wastewater disposal __�%'3-compartment sink `Electrical hook-ups <br /> ET"Solid waste disposal ::9 Food preparation 'filet and handwashing <br /> d1 Id t & Cold water for cleaning � a Store refrigerated food otable water <br /> S red food suppli sSOvernight parking Vehicle wash <br /> I, 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�allnyth HD immediately. <br /> Signature Date <br /> 3. o be completed .6y:the:ENV HEALTH jP sdi6.&h c utside t Saris ,foaq >In 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 /> REHS Signature Date <br /> 1868 E. Hazelton ,Avenue j Stockton, California 95205 j T 209 468-3420 1 F 209 464-0138 1 w4vw.sigov.org/ehd <br />