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SAN JDAWN Environmental Health Department <br /> —COUNTY— <br /> . <br /> Greatnes <br /> OUNTY— <br /> Greampss arows here, <br /> COMMISSARY.AGREEMENT <br /> Mobile Food Facility#-Caterer <br /> Complete sections I and 2. If your commissary is located outside of San Joaquin,County also complete. section 3. <br /> ' <br /> Business Name'6LI-/a Ila irt Oyiniu C-10,1= <br /> _WPlate# &V1,215 <br /> Owner/Operator Name <br /> Business Mailing Address #,2 <br /> JaB Q01k iq ep <br /> Cit State - ip _�Bus. Ph.(Zq)7y0-JVO'/Alt. Ph. <br /> ereby state that the above information is current,true and correct to <br /> the est of my knowledge and ree t fi y approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquil ty E vi 4Th ntal Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued a per 0 Id u notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Sigrjature late <br /> - M41. WKEWK.W <br /> ), <br /> Commissary Name (C 1< Jnz C, 0 ::2-'C e fL20 A N1 —FA#— <br /> Address Ll I l L rn OZ r- -p r+V,,:= <br /> Bus. Phone �01_ 0�k?- <br /> CitY"-9'70 e-tC7 .�l Zip C& or< 3a S- Owner/Operator jtT <br /> N <br /> Check all appropriate services provided: -4 <br /> 0 <br /> 13 Wastewater disposal E3 3-compartment sink XZ-'81ectrical hook-ups0 <br /> il X <br /> 0 Solid waste,disposal El Food preparation Ukfoilet and handwashing , --i M- <br /> 0 <br /> E3 Hot & Cold Water for cleaning U-18tore refrigerated food 13 Potable water z — C <br /> z <br /> 0 M RE3 Store dry food/supplies0-dvernight parking 13 Vehicle wash > <br /> hereby state that the information I have provided is current, true and > <br /> < <br /> corf�ct to'the best of my knowledge,and meets theC21if0mia Health&Safety Code requirements. If the food facility K) M rr <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 Date_ <br /> .T 6_m <br /> plef the ENV uis d;.r' "A'WO 04�018 8_ 0.J0aq, Qi6wcu <br /> : j: " <br /> , MI <br /> The commissary is located in County. The above food facility meets thel <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 /> t' <br /> REHS Signature ate <br /> 1868 Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd If <br />