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SAN �JOAQUIN <br />—COUNTY— <br />�reetness crows here. <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility *.Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin,County also complete section 3. <br />1 To;:be co[ri feted by APPLICANT` <br />Business <br />Owner/Operator <br />Business Mailing <br />a t e # R/fd 1,2 1"5-(1 <br />the -best of my kriowl4dge and <br />Safety Code, and San Joaqui <br />commissary is discontinued ie K <br />revocation and penalties. <br />Bus. Ph.(Zq) 710 _5%0YAlt. Ph. <br />q state that the above information is current, true and correct to <br />approved commissary in accordance with California Health & <br />rtal Health Department (EHD) requirements. If the use of the <br />notify the EHD. Failure to notify this office may result in permit <br />2: To. be;coinplefed by COSSARY OWNEWPERATOR <br />Commissary Name P I C k V G Q fqC c r Rii- R MI FA# <br />Address 3 U9 I ,,) )E-:, rn ; nP 'a fa V [: Bus. Phone > of oN,P-- I1 G�— <br />c/ <br />City S i c ri s i s/ Zip c/.1 or c. _ qL - Owner/Operatorep L�4 ,. I) <br />Check all appropriate services provided <br />® Wastewater disposal 13 3 -compartment sink XY Vlectrical hook-ups <br />® Solid waste,disposal 0 Food preparation if oilet and handwashing <br />© Hot & Cold .`water for cleaning amore refrigerated food 13 Potable water <br />® Store dry food/supplies Zk6vernight parking E3 Vehicle wash <br />I, , hereby state that the information I have provided is current, true and <br />correct td 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 N�/ii S �, �j S' <br />'c Date l-`.2L4-4:1� <br />R <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.sjgov.org/ehd <br />U) <br />W 0 ;K <br />n N Z <br />—IMC <br />Z -C <br />0 n rr <br />D x <br />+" <br />C)M <br />