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y <br /> ^ N.,JV( DI+ vp Vo} MNnnNRHealth Department✓ B }m p <br /> Ad, .-.. ;.ilk TY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections 1 and 2. If your commissary,'s located outside of San Joaquin County also complete section 3. <br /> RX <br /> . F <br /> Business Name c. Plate# i.J R-1 <br /> Owner(Operator Name <br /> Busine Malti g Address S <br /> City Stat Bus. Ph. Alt. Ph. <br /> I,------- ��- hsreby state that the above Information is current,true and correct to <br /> the best of my knowledge and agree to utilize my aooroved commissaryin accordance with California Health & <br /> Safety Code, and Sen Joaquin County Environmental Health Dopartrnent (EHO) requirements, if the use of the <br /> corrlmisaary Is 'iaco: ir,ued,the Perry,11 holder must notify the EHO, Failure to notify this office may r(.suit it, poffrit <br /> f0vocation an t <br /> l� , <br /> signature, m Date <br /> _ g <br /> ,'Commissary Nam I <br /> Address t Bus. Phone Z <br /> Cit V1 _ -.?Ip-C - --Owner/Operator <br /> Check all appropriate services provided; <br /> ' Nastewater disposal �rompsrtment sink 0-E-Tectrical hook-ups <br /> �,�„' <br /> solid waste disposal )3 Food preparation VToilet and handwashing <br /> Ho & Cold water for cleaning tore refrigerated food Potable water <br /> Stare dry food/supplies r vent ght parking icls wash <br /> hcreby ::.ate that the information I have provided Is current,true and <br /> correct to the best of my knowisdge,and meats the Cslitorn(a Health rs Safety Coda requirements, If the food facility <br /> operator fella t mply with 00 conditions of tris agr&erndrtt, or If Ola agreement I modified or c-ancalled, the <br /> c missary o erali no the ,O immediately. <br /> r !/ <br /> Signature nate, <br /> Thra commissary is locsted in county. The soave food facility meets the <br /> commissary requirements in California Health to Safety Cadc. The above checked services are available at the <br /> above commissary. Please notify EHO if the status of their operating permit changes. <br /> REHS Signature <br /> 1883 E. Hazeilnn Avenue I Stockton. Caiifcmia 95205 i T 209 463.34201 ? <br /> F 09 .464-01. <br /> - 33 j wtr,m.sigov,orvgiynd <br />