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SAN J O A Q U I N Environmental Health DepaB ewnu`- <br /> COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile- f=ood Facility % Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> Business Name Lic.Plate# (j I <br /> Owner/Operator Name // <br /> Business Mailing Address Z/ 7�Z <br /> f • <br /> City ! _Stat zip 9s ra Bus. Ph.a b 576 �7 yy Alt. Ph. <br /> hereby state that the above information is current,true and correct to <br /> the best of my I; owled a 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 D G U� 2 01l <br /> , <br /> 2n To be completed by COMMISSARY OWNE OR �^ <br /> Commissary Name L r k LM'(hP:Ck FA#/ <br /> Address � � E t>ti ,-�� c �C�w Bus. Phone O�A • Lit (Q 14 <br /> City -�'D�O C'�4AGV1 Zip at-' Owner/Operator .�: A t nL:�-�C <br /> Check all appropriate services provided <br /> Wastewater disposal V3-compartment sink — EI ctrical hook-ups <br /> olid waste disposal Food preparation ;/�R <br /> ifet and handwashing <br /> of& Cold water for cleaning Store refrigerated food ablewater <br /> M are d food/sUpplies Ovemight parking Vehicle wash <br /> dry <br /> I, yxz Vl�F N�� Z 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 /> commissary n�}shall notify .the EHIJ16med1lately. <br /> re <br /> Signatuz%�� —2ti� u-a -- ._. <br /> _.._.- Date <br /> >> o be completed by the ENV HEAL T H "urlsdicdon outside of San Joaquin 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 /> 'i 868 E. 'eazelton Avenue i Stockton, California 952051 7 209 463-3420 1 F 209 464-0133 1 w�.�urnr.s;gov_org/ei id <br />