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SAN JOAQUIN Environmental Health Department <br />--COUNTY__._ <br />Greatness yrows her". <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 />a w i e 2- ..Zrz 1 e i� t +. s'9a°gVs 4k 5 J iii; To°Erie=conn";Iet�d-�t� 1XR�'�I�(��i�T.~� � <br />Business Name 5 -NIW-% 7 Cs0- <br />Owner/Operator N <br />Plate# U ryAS3�i U <br />Business Mailing Address / a 5 r P A.99-" 4h pa , <br />City�'�/ StateLAZipq L Bus. Ph.aVq 6b�Alt. Ph. <br />I, , 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 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 anA,penalties. .p n <br />The <br />2.`=Ta',be:cafri <br />leted:b; S,4R'�MOtI�tNE0 ERATO <br />W <br />R',3", <br />.CL7MMI <br />Commissary Name P 1 C IC fl/ c, c, 9 C i-_ c-goq (n FA# <br />Address -32/2 E n r,' n/E VC Bus. Phone <br />City S %o !f14 %or✓ Zip -A 61SS�'� S' O er/Operator c c. p N � <br />n <br />-11"' <br />Check all appropriate services provided: p 3 x <br />[3 Wastewater disposal ❑ 3 -compartment sink P -Electrical hook-ups Xn� Z <br />4 O <br />❑ Solid waste disposal ❑ Food preparation ❑ Toilet and handwashing O ;;y O <br />� � — <br />❑ Hot & Cold water for cleaningZ <br />ED -Store refrigerated food ❑Potable water n <br />0F1m <br />❑ Store dry food/supplies RlOvernight parking ❑ Vehicle wash D %n <br />D <br />I, hereby state that the information I have provided is current, true and (n <br />;acorrect to the best <br />knowledge, the California Health & Safety Code If m D <br />of my and meets requirements. the food facility C <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the cn 3 <br />commissary owner shall notify the EHD immediately. <br />Signature�xm� S Date <br />13_7o0 ethe <br />ENV HEALTHU'risdietionrdu�dCdI'lljseoaJunb <br />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 <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 />