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cr <br /> S AN }OA U IN <br /> Environmental Health Department <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 /> lig !I! 1111a: <br /> Business Name ROCY-IES t1EXOAV kkTCqF-N Lic. Plate#-66�) <br /> Owner/Operator Name ?=PaUF1L- ZAf ket� <br /> Business Mailing Address <br /> State Or ZiPOT59 it. Ph._ <br /> ;�xjp Bus. Ph. <br /> Rpgito- vwkl:lO , 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 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. Z <br /> Signature Date / 1(L <br /> .... . .... . <br /> ZIP <br /> Commissary Nam <br /> Address Rim Phone <br /> City 1, Zip w er/Operator <br /> Check all appropriate services provided: <br /> 04astewater disposal P/3-compartment sink MIElectrical hook-ups <br /> GrIsSolid waste disposal 2 <ood preparation GKT'oilet and handwashing <br /> t & Cold water for cleaning 13 Store refrigerated food o able water <br /> Store dry food/supplies M-Overnight parking nVoehicle wash <br /> 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 t -7 mply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> Commissary 0 er If.Zno the D immediately. <br /> -., <br /> Signature. Dae I L2 , <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Coda he 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 4Q P I-) <br /> 1868 E. Hazelton Avenue I Stockton. California 952'5 i T <br />