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".,. SAN. JOAQUIN Environmental Health Department <br /> —cauNTY— <br /> _ :.•r <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility+ Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3; <br /> �.'`.l'�{�....A..... '.. /.y�,,�A'9 J - An l�'LRl�bkt4�1 .�-:1. im ..iw.. ..!.Ck'H y:,s�ip biY' •.x4' v r'��'R'#. <br /> Business Name Lic.Plate#fn3� <br /> Owner/Operator Name (� <br /> Business ailin Address <br /> Cityl�StatipMS Bus. PhGV 1 0 TJ I Alt. 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 Co my Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, the pe [der must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date <br /> Commissary Nam <br /> Address3V. Q✓ Bus. Phone vl <br /> City , Zip--�� l � Owner/Operator I <br /> i <br /> Check all appropriate services provided: <br /> 0-Wastewater disposal CT1 3-compartment sink 0"bectrical hook-ups <br /> _ Solid waste disposal mood preparation FYTToilet and handwashing <br /> Xi"/Hot& Cold water for cleaning Qttore, refrigerated food 0-fDotable water <br /> 13"Store dry�food/supplies i5�SOvernight parking p Vehicle wash <br /> (, hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary o ner sha0 notify the EHD imme ' tely. jj /I <br /> Signature ¢J��T /l� Vl/' Date I / S 1 I'Z,1 <br /> Lan— <br /> yaw <br /> r¢' �"�v �j '�`y,3p-��'j ° ��.. yi1//.CY(l'11L �y.yy. <br /> #.,/..... _.. .Mc,I�`ll A.FE{`.'�`<C�1V'�G � ..�'�i{ IY�SS�(l�ik`l.\'_Y <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 /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.slgov.org/ehd' <br />