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SANAMUIN Environmental Health Department <br /> —COUNTY— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections f and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br /> age <br /> Business Name Lu -,b— 9 e4z2e) Lic. Plate# IZ � <br /> Owner/Operator Name D <br /> Business Mat ti g dress L- U <br /> City tate Zip Bus. WhWl)(�J3353q Alt. Ph. <br /> I, 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 Environmentai Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued,the permit holder most notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature�_1�Q !�fJ 5 k V,"6! -j-L Date �� /� <br /> I; �t <br /> Commissary Nam r f/1 <br /> Address 3-D . 5 . r Yl TO Bus. Phone I <br /> City L ,() Zip . ()42D3 Owner/Operator e <br /> Check all appropriate services provideed:� <br /> Wastewater disposal CY3-compartment sink Ca Electrical hook-ups <br /> lid waste disposal 13 Food preparation ��oilet and handwashing <br /> Ld Hsot& Cold water for cleaning �re refrigerated food E Potable water <br /> ! e d flood suppii vernight parking @"Vehicie wash <br /> /� hereby state that the information I have provided is current,true and <br /> correct to the best of my Rnowledge,and meets the California 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 modified or cancelled, the <br /> commissary o r all n th HD imri ly. i e2) 2, <br /> Signature sir 'T/�if'� Date � <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 1 www.sjgov.crglehd <br />