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SAN OAUI & <br /> Environmental Health Department <br /> --[OUNTY-- <br /> G/ooioo. p,o/;she/�. <br /> COMMISSARY AGREEMENT <br /> �,��n�oo�on��^�x~�xn. nx~«�po��~�~nmxu~x� n <br /> Mobile Food Facility ,) Caterer <br /> Complete sections / and-2 0ixourrunnxisoag/islocated outside ofSan Joaquin County also complete section3- <br /> -1 <br /> 8usinesaNarna Liu.P|ato <br /> Om/Aer/UperatnrNon1 <br /> Business Mailing Address <br /> City Bus- Ph |t. Ph. <br /> | �~ ' hereby state that the above information iocurrent,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 pe al ' s. <br /> Signature Date SL <br /> F2. To b,e completed by, COMMISSARY OWN MQPEH�V <br /> / <br /> Commissary Name <br /> Address 2 ' ryigN ~^ un. phun r\ /-7t, <br /> city 9rocZipCla OfOw8e�Oporato <br /> Check all appropriate services provided: <br /> � <br /> [3Wastewater disposal U3'connp8dnAoAtsink "eutriuu| hunk'ups x M <br /> , <br /> Ej Solid waste disposal E3 Food preparation D'Toi(etand hand\washiAg <br /> E3Hot & Cold water for cleaning 0--nnrerefrigerated food UPotable water <br /> �o m | <br /> E3Store dry food/supplies 9"ve|nightparking E3Vehicle wash > ;a | <br /> |. <br /> hereby state that the information | have provided iscurrent,true and Cn <br /> ' <br /> correct to the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility " M <br /> CD <br /> operator fails tocomply with the conditions of this agreement, �M � <br /> ` � <br /> commissary owner shall notify the EHDimmediately. <br /> Signature <br /> " <br /> 13.,To be completed by the ENV HEALTH jlJ!risdj6fi.67n` %sj� �Co. <br /> The commissary islocated 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 EMDif the status oftheir operating permit changes. <br /> REHS Signature Date <br /> 1D68EHazelton Avenue I Stockton, California 852O51T2O94§0'34201F2O9454'V1381w«ww.:i3ov»r0/rhd <br />