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SAN JOAQUIN -1 ircffl M'M' fiftafth 00P I —,qen <br /> E_6 1 V j 0, ,tritl 0 L an!" <br /> —COUNTY— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o- Caterer <br /> Complete sections 1 and Z If your commissary is located outside of San Joaquin County also complete section 3. <br /> Fl. TQ be corng.leted b APPLICANT L;ic-Plate t <br /> Business Name ic.Plate <br /> owner/Operator Name <br /> d jr, &@ t W1 <br /> Busine s Mai'ng Address <br /> cityqC61 StateQ--Zip S� B I us. Ph209.a f <br /> I �LZILEAlt. Ph. <br /> 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 /> 12. To be completed by COMMISSARY OWNEWOPERATOR <br /> Commissary NamX4 iw i z N,A-evf m 1� <br /> Address-1b C) cA )l y-rl I g Bus. Phone <br /> CitVSADC zip_ �� OlAfnerlOperatorPA Vq d oy, V)U-M <br /> Ch k It <br /> .7e a appropriate services provided: <br /> Ea Wastewater disposal D'13-compartment sink electrical hook-ups <br /> Er-Solid waste disposal Food preparation EYToilet and handwashing <br /> M4ot&Cold water for cleaning E3 St re refrigerated food 17'Potable water <br /> 0--s't'ore dry food/supplies � St <br /> parking 0,-Vehicle wash <br /> 1, hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,and meets the Calffornia Health&Safety Code requirements. If the food facility <br /> operator fails to1p ly with the conditions of this agreement, if this agreement is modified or cancelled, the <br /> commissaryo _�_ <br /> a �Fotify HID,1penediately. <br /> 12, ) <br /> 3. To 136 com feted b. .the ENV HEALTH juftsdictiotn outside of San Joaquin,go.] <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. Hazefton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 wmv.sjgov.org/ehd <br />