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SAN JOAQUIN Environmental Health Department <br /> —C '-)UNTY— <br /> Grreotr,•5s grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility • Caterer <br /> Complete sections land 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> W. o e cor lefjdc " <br /> Business Name 1 - , _ �zv �c Lic. Plate# ( (`(`, <br /> Owner/Operator Name ac.,,.vtas.-(. <br /> Business Mailing Address 1 V ,�rcr l h[Yi� IJV <br /> City c State WZip — r ( Bus. PhEZffi1 h12-loar� Alt. Ph. <br /> I, hereby state that the above information is current, true and correct to <br /> the best of my nowledge 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 andenalti <br /> Signature b.K %( /G( Date 12 —0— <br /> i 2. To be completed by COMMIS R O " FF <br /> Commissary Name rt FA# <br /> Address l712 ��6�i�1�c�t���rr s•� Bus. Phon 2'G%) .22Y My <br /> City 1-b n I' Zip 2`//h Owner/Operator A/,.-A Iry 4�&e6 <br /> Check all appropriate services provided: <br /> Wastewater disposal compartment sink It�Electrical hook-ups <br /> EF,-'Solid waste disposal �ood preparation MToilet and handwashing <br /> — s� <br /> Hot & Cold water for cleaning PStore refrigerated food 121�`Potable water <br /> d Store dry food/supplies Overnight parking 13'vehicle wash <br /> I, 1,0m t i l5AeY 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 owner shall notify the EHD immediately. <br /> Signature 499 AvL Date <br /> 3. To be com leted by the`WHEA H'jurisdiction outside of 8an'Joa ucuiin Co. <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 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />