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SANAMUIN Environmental Health Depart-gent <br /> ` <br /> —COUNTY-- <br /> COMMISSARY AGREEMENT <br /> Mobiie Food Facility ♦ Caterer <br /> Complete sections 1 and 2. ff your commissary is located outside of San Joaquin County also complete section 3. <br /> Business Name 1i f� LOW tic. Plate#�� �) <br /> Owner/Operator Name Lf�� <br /> Busine s Mailing ddress nt2 U <br /> City l�tate_Zip��Bus. PtxO/Iay1 l 5' 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 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 V 6c'taY d. �� Zr-✓ Date__� 2 <br /> Commissary Nam n n-tC�11 <br /> Address Y n C4 Bus. Phone 2 <br /> Cityy L_�0Zip Owner/Operator 1/ en +it <br /> Check all appropriate services provided: <br /> wastewater disposal 1 3 compartment sink 0-flectrical hook-ups <br /> H Solid waste disposal O'rood preparation R-1 oilet and handwashing <br /> Iot Cold water for cleaning O Store refrigerated food ).Potable water <br /> S e d food suppli s 0-Overnight parking chicle wash <br /> I, / 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 corn ly with the conditions of this agreement, or if this agreement is modi ied or cancelled, the <br /> commissary o r all n tify th JiD immediatel�y./�/ �/ <br /> Signature �_ �• sL7�,�--/lir� Date � I /L <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 1 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />