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s 'A^ Environmental Health Department 't —COU N i v�_ L cr€as ess 'gr-ars. ere. : COMMISSARY AGREEMENT Mobile Food Facility o Caterer 'r Complete sections 9 and 2. If your commissary-is located outside of San Joaquin County also complete section 3. 100"IN Business Name wp'ccic) 5 I Tf� Lic. Plate; 2VA Owner/Operator Name . S Busin ss M ilin Address r r City State ip Bus. P _ 661t• P.h- r 1, l hereby state that the above information is current,true and correct to .the best of my knowledge and agree.to utilize my approved commissary in accordance with Caiifomia Health & Safety Code, and San ,loaquin Cou vironmental Health Department (EHD) requirements. if the use of the commissary is disconti ed, the ermit h der must notify the EHD. Failure to notify this office may result in permit revocation and penalt' s. Signature DateWE I Commissary Name Address _0. S - ( M us. Phone �_o r CiZi A Owner/Operator Y �sA ty zip —A all appropriate services provided: Wastewater disposal UL/3-compartment sink 13Electrical hook-ups olid waste disposal 0 Food preparation and handwashing Hot old water for cleaning Sto refrigerated food Po ble water S e d food sup li Overnight parking Vehicle wash Pia l hereby state that the information i have provided is current.true and correct to the best of my no-Medge, and meets the Caiifomia Health&Safety Code requirements. if the food facility operator fails to com iy with the conditions of this agreement, or if this agreement is modified or cancelled, the commissary o r all n th HD immediately. Signature Date The commissary is located in County. The above food facility meets the commissary requirements in California Health & Safety Code. The above checked services are available at the above commissary. Please notify EHD if the status of their operating permit changes. REHS Signature Date 1868 E. Hazelton Avenue I Stockton, California 95205 } T 209 468-34201 F 209 464-0138 1 www.sjgov.orglehd