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M <br /> T 'fel i'lNAVI UIN E­ vitonmentai i eafth. Department <br /> f�'E�aent <br /> � <br /> --BOUNTY-- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility • Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> Business Name Cts M VFO M Lic. Plate# <br /> Owner/Operator Name J VVt 1 I <br /> Business Mailino Address <br /> City L Stat Zip ZQsBus. Ph26IlM S Alt. Ph. <br /> I, J ,hereby state that the above information is current,true and correct to <br /> the best of my knowledg& and agree to utilize my approved commissary in accordance with CaJifomia 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 nalties. R �^ , 1 <br /> Signature ne I I'U Date rj <br /> Commissary Name I 01 <br /> ress <br /> Add 'ZDD <br /> C Bus. Phone (, <br /> City Zip 52bOwner/Operator �� (/a L QST <br /> Check all appropriate services provided: <br /> wastewater disposal CK3-compartment sink CV61ectrical hook-ups <br /> solid waste disposal 0-fo-cid preparation Q—Ta-let and handwashing <br /> Ct of&Cold water for cleaning 13 Store refrigerated food 13-Potable water <br /> rye d foo suppli s overnight parking QVsfiicle wash <br /> I, hereby state that the information I have provided is current,true and <br /> correct to the best of myknowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator faiZ15 <br /> th the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissarIffy th HD immediately. <br /> SignatureiA! Date �W V <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 : T 209 468-3420 1 F 209 464-0138 ! www.sjgov.orgiehd <br />