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SHAUN Environmental Health Department <br /> " , l —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 /> 1--Tobe eom leted;ti. APPLiCA�iT'_= <br /> Business Name Fj Lia Plate# <br /> OwnerlOperatorName��p �'�^" o kz:j2 <br /> Business Mailing Address `L120 & // !Z7 <br /> city � �Dx4d1 -Lh5 Alt. Ph. <br /> I AJ e5l&L 0 Ct'/Lvj�2 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 Z? � o 6-crdLi7,� Date 1�2 <br /> 2jo betorrt Iditedb.:COMMISSARY OiNNERIOPERA1'OR <br /> Commissary Name_j A <br /> Address k�ft Bus. Phone LL (7_ L15 70 <br /> City ���Zip OwnerlOperator <br /> Check all appropriate services provided <br /> wastewater disposal �7 3 compartment sink - EI cal hook-ups <br /> eSolid waste disposal [3 Food preparation �:Zi:et handwashing <br /> OHot&Cold water for cleaning ® Sto refrigerated food Cd P' ble water <br /> S/��re dry food/s�up_plies Ovemight parking Vehicle wash <br /> I, ( p�llj6 / RAIA � 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 /> commissarynev`shall notify the E ammediately. <br /> Signature ' - - -- Date /,,L <br /> 3..Tip lie corn leted e!-ENV HEALTH oiqutiida+ ,Joe ,uin 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 I Stockton,California 9520511 T 209 468-34201 F 209 464-0438 1 www.sjgov_orglehd <br />