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SAN 10AQUIN Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility * Caterer <br />CmT. k,le secl,er,as1 ancf2. It your cu.!vrrissa�yis kx-alcmJ oulwd- of Sin doayu+n Cuunay 9su c=pkele seclum 3. <br />l To be completed by APPLICANT <br />Business Nance _l �� ' -------i - _Lic. Plate #(142_l�V <br />Owne#Operator Namaj <br />Business Mailing Address„ <br />City r TStab,_ ip_ Bus. Ph.2." I— AIt. Ph-� <br />I, Wh 'r It m -or Ve 2 , hereby state that the above informalion is current, true and correct to <br />the basi of my knowledge and agree to utilize my approved commissary in accordance with Caifomia Health 8 <br />Safety Code, and San Joaquin County Environmental Health Department {EHD) requirements. If the use of the <br />cormnissary isdiswrit"d, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and <br />�penalties. i j <br />Signature t't�� 1 Y7 tl-1 1 Z Dale n .41� — 2c) — ` -z� 2 <br />Check all appropriate services provided: <br />Zastewaterdisposal rb 3 -compartment sink Aa'Electricai hookups <br />dSolid waste disposal Ef Food preparation J34oiletand handwashing <br />Ad Hot S Cold water for cleaning dStore refrigerated food Potable water <br />Id Store dry f suppler dOvemight parking {'Vehicle wash <br />I,a `ia CCW -hereby state that the information I have provided R cur re rd, true and <br />carrectto the best of my knowledge, and meets the California Health 8 Safety Code requirement.. If the food facitdy <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />oomrrrssaryfemer shall notify 1h,5EHD immediately. 1 <br />i o <br />Big <br />3. To be <br />the ENV HEALTH lurisdictlon outside of San Joaouln Co. <br />The commissary is located in .Sf'G tf/.x i. X Zj:� LSAfWrity. The above food facility meets the <br />commissary requirements in California Health E Safety Code. The akbve checked services are available at the <br />above commissary. Please notify EHD f the status of their operating permit changes. <br />1 -.UW <br />1868 E. Hazedon Avenue I Stockbn,California 95205 1 T 299468-342,7 I F 209461-0138 lwww.slgoo.or9iand <br />