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SANJOAOUIN Environmental Health Department <br /> —COUNTY-- <br /> j <br /> COUNTy-- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 4 Caterer <br /> Complete sections land 2. If yourcommissary is located outside of San Joaquin County also complete section 3. <br /> 9: To be coni leted b APPLICAdVT <br /> Business Name /' Lic.Plate# <br /> Owner/Operator Name 40, <br /> Business Mailing Addres 7 <br /> City. • el StatJ�-Zip a0 _Bus. Ph.,9Dy-51 %q 12,0 Alt, Ph. <br /> I, ' 04!?e I Q I D Ila 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 acid penalties. <br /> Signature Y, Date <br /> 1 To be coieiple-ted.by COMMISSAR-Y OWNER/OPERATOR <br /> CommissaryName LA FA# <br /> Address '�AC+.rAA ni, i e,,w Bus. Phone <br /> City F� ��� Zip ii'> Owner/Operator n2 k <br /> Check all appropriate services provided:: <br /> Wastewater disposal mC 3-compartment sink -- EI •ram hook-ups <br /> olid waste disposal Food preparation --/Toilei and handwastring <br /> �ot& Cold water for cleaning U Store refrigerated food i/ P ble water <br /> 9e dry food! lies '' Overnight parking Vehicle wash <br /> I, ONmi <br /> c �/(N ltdt:�O­ hereby state that the information I have provided is current,true and <br /> correct to the best of my Imowledg%and meets the California Health&Safety Code requirements. If the food facility - <br /> operator fails comply with the con�ns of this agreement, or if this agreement is modified or cancelled, the <br /> commissa owngi shall notify tl = mmmediateiy. <br /> Signature d r e � � Date <br /> Si T.b be Completed-by ft:ENV HEALT FI jurisdiction outside bf Sati'Joa 6M Co. <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 /> RENS Signature Date <br /> 1868 E_Hazelton Avenue I Stockton,California 952051 7 209 468-34201 F 209 464-0138 1 www.sigov_orgleFrd <br />