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SAN :lOAQUIN Environmental Health Department <br /> + —COUNTY— <br /> ``4 Grec"mess gra��s r.: - <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections 1 and 2. ff your commissary is located outside of San Joaquin County also complete section 3. <br /> LICANT <br /> Business Name rr77'1 V A' Lic. Plate# <br /> Owner/Operator Name— <br /> GI V <br /> Bus'n ss Mail' Address L l <br /> City StateZip95iL (2Bus. PQ-09 q&610 It. Ph. <br /> I, hereby state that the above information is current,true and correct to <br /> the est of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, nd San Joaquin County Environmental Health apartment (EHD) requirements. If the use of the <br /> commissary i discontinued, the permit ho l ust notify t EHID, Failure to notify this office may result in permit <br /> revocation an p ' <br /> Signature I 1 Date ! <br /> 2. To t <br /> _ <br /> Commissary Nam r a �Y 1 (✓ V & <br /> Address MNAV'Yli S4 Bus. Phone <br /> City Y) Zip05?L Owner/Operator K %[VArA <br /> Check all appropriate services provided: <br /> 0--Solid <br /> disposal Q.-compartment sink �ectrical hook-ups <br /> 0 Solid waste disposal Ck<ood preparation Clfiilet and handwashing <br /> C�'1 Hamot& Cold water for cleaning Store refrigerated food �taIe water <br /> G S e d food suppli s ��ernight parking le 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 Califomia 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 modfi,d or cancelled, the <br /> commissaryo r all n th/e/AHD immediately <br /> Signature iz` �2c�,�ir�� Date L Z <br /> The commissary is located in County. Tne 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 4640138 1 www.sjgov.org/ehd <br />