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V'F4(iAL UIN 5 iri'virorltdentaYHealth Department <br /> COMMISSARY AGREEMENT <br /> Mobile rood Facility + Caterer <br /> Completesections9 and 2. !f your commissary is located outside of San Joaquin County also complete section 3. <br /> .. <br /> Business Name >� M. n�11z1S�S S��11�p1Lic. Plate# <br /> Owner/Operator Name 2 2 -V� �Z <br /> Business Mailing Address J ��pp e S <br /> City State�Zip it Bus. Ph S0 dS Alt. Ph. <br /> hereby state That t'ne above information is current,true and correct to <br /> the best or my knowledge and agree to utilize my approved commissary in accordance with Califomia 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. n n <br /> Signatu-8 Date W 2 <br /> PINT:' <br /> _.__ ..._., _:... _ :: <br /> WON <br /> Commissary Nan C' <br /> Address r 11 Bus. Phone Lm 2 I K <br /> c <br /> City C Zip �jSZo3 Owner/Operator V"- VL11 rzis <br /> Check all appropriate services provided: <br /> 5Wastewater disposal compartment sink C E ectrical hook-ups <br /> SofSolid waste disposal �;kl-ood preparation r et and handwashing <br /> 15 Hot&Cold water for cleaning C1 Store refrigerated food f"-Potable water <br /> tC e d food suppli s E�night parking Q V6fi_icie wash <br /> I, '�hereby state that the information 1 have provided is current,true and <br /> correct to the best of my nowledge,and meets he California Health&Safety Code requirements. Ifthe food facility <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissaryo r all r1ty th HD immediately. <br /> Signature rf �. �R �� Date 2 V 21 <br /> e EN t °r11 TH t��S7Ll9P'A0Y;Y Tb 4LiRfiQ YS7 Z�l2b RfS W �� <br /> 1 <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in Califomia 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 /> RENS Signature Date . <br /> 1968 E. Hazelton Avenue 1 Stockton.. California 95205 ; T 209 468-3420 i F 209 4664-0138 1 wunv.sjgov.org/ehe <br />