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SAN ,� OAQU I N Environmental Health Department <br /> COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility a Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> A',Y �• d u� }r t <br /> so. �.q s ,....R <br /> .,..., _ <br /> Business Name �� 0 0 `�1 O,- Lic. Plate <br /> Owner/Operator Name C V1 S' <br /> Busin s Mailing Address IA VYLq C4 / <br /> City Seo �State� Zip I 2 Bus. Ph.�� 6D 16 "I � Alt. Ph. <br /> I, 2� �ej \ V^V`e- , hereby state that the above information is current, true and correct to <br /> the best 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. L� <br /> Signature "---- � I Date <br /> 00T „h.'t ..J <br /> Commissary Name I VI ck a <br /> Add re s <br /> ��, 0411 ti C�(_n v1 -Bus. Phone <br /> City L Zip 2� Owner/Operator ,> (1 VuL( Y/- (A e i <br /> Check all appropriate services provided: <br /> p"WVastewater disposal _-0'3-compartment sink EIIE—lectrical hook-ups <br /> EY'Solid waste disposal L7'Food preparation ��ilet and handwashing <br /> I~l Hot & Cold water for cleaning ❑Store refrigerated food [a-'Potable water <br /> Ee d food suppli s t] Overnight 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 oYr=alln �y th HD immediately. <br /> Signature Date I 12 <br /> ti <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 />