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ptnll <br /> ` JW � �� VN: MmviyWmmktai Health <br /> ealjh Deap}me t <br /> K .r.Y--- <br /> COMMISSARY <br /> _ .COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections ' and 2, If your commissaryis located outside of San Joaquin County also complete section 3. <br /> Business Name_ Lic. Plate-, L V20 E Yo <br /> Owner/Operator Name Z <br /> Busines Malling ddress_ L ��_ <br /> Ci- tate ip0��Bus, Ph. D S�� ) _Alt. Ph. - -- - <br /> _ hereby state that the above Information Is current,true and correct to <br /> the bast 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 (EHO) 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 /> Signature � RC2 V �} d�B3f' ^nate 2Y) Z <br /> t <br /> Commissary Nam Dl IMt <br /> Addres - Bus. Phone <br /> C141 <br /> ity (, Zip Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal 0/3-compartment sink Electrical hook-ups <br /> If Solid waste disposal Mood preparation /157oliet and handwashing <br /> M�Hot & Cold water for cleaning g-Store refrigerated food potable water <br /> rL store dry food/supplies IBJ S2vemight parking Z 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 California Health&Safety Code requirements. If the food facility <br /> operator falls t$�bmply with the conditions of this agreement, or if this agreement Is modified or cancelled, the <br /> commissary to far 11 not,fy the O Immediatel , <br /> Signature n� Data <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 95205 i T 209 468-3420 I F 209 464.0138 1 www.sjgov.orglehc <br />