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SQsQAQUIN Environmental Health Department <br /> I-L <br /> —COUNTY— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility t Caterer <br /> Complete sections f and 2. If your <br /> �ccommis�ssaaryyis located outside of San Joaquin County also complete section 3. <br /> 77MM <br /> tC��/S 5t1D26� �U J6 (;h11��Y�'it�ic. Plate# L� b <br /> �IrY-Ptd �' - � p��is ��� l Tlt �f�� f`City State�Zip Bus. Ph. d 3LKO Alt. Ph <br /> 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 and penalties --- i <br /> Signature Date <br /> 2. To be com feted b C.gMM1SSAf � it <br /> Commissary Name <br /> SBus. Phone <br /> Address <br /> City ZipJ=Q�,_Owner/Operator <br /> Check all appropriate services provided: <br /> astewater disposal Er 3-compartment sink SALVZCW%9199IR�lAb1� R4 ups y:.• ::,;. <br /> DBA CALI79d S G'ffl#JVSY"� <br /> El"Solid waste disposal i3'Food preparation ming <br /> O Hot & Cold water for cleaning �`Ztve <br /> ore refrigerated food ST 1 M9T9r <br /> rni ht arkin f3 Vehicle wash <br /> Store ry food supplies9 io g. <br /> 1, S GCI f61 a 0 hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,and meets the Califomia Health &Safety Code requirements. If the food facility <br /> operator fails to comply with the conditionsof this agreement, or if this agreement is modified or cancelled, the <br /> cogmmissaryy oy✓neerr shat ptIf the EHD imm \tely. / <br /> Signature �'llll 1111 \\ll I Ill V�ilyll�[j(n Date l I o <br /> 1 <br /> isdrgt�oni�aud06fano s <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 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />