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S A N-�J 01 Q U I N Environmental Health Department <br /> —COU TY— <br /> Greotness gr . r; =, <br /> OMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections f and 2. 11 your commissary is located outside of San Joaquin County also complete section 3. <br /> Business Name /hC-- Lic. Plate# -1/1/!OG V <br /> Owner/Operator Name GPi/ /9, .tkf <br /> Busine s Mailing Address edO S <br /> City Stat Zips j0 Bus. Ph.(a527J A Alt. Ph. <br /> I, hereby state that the above information is current,true and correct to <br /> the best of my knowledge an J agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, a San aq ri County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is Conti ed, ie permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation a ena <br /> Signature Date <br /> a <br /> Commissary Nam FA# <br /> Addres Bus. Phoned&?—y(vy-�/5`7D <br /> City Zip qsd S' Owner/Operator Q N,6;' <br /> ,,6 QA"7ti i <br /> Check all appropriate servi as provided: <br /> M Wastewater disposal (9 3-compartment sink M Electrical hook-ups <br /> 19 Solid waste disposal 0 Food preparation ® Toilet and handwashing <br /> 93 Hot & Cold water for cleaning ® Store refrigerated food M Potable water <br /> © r dry food/s ies M Overnight parking Ed Vehicle wash <br /> I, hereby state that the information I have provided is current,true and <br /> correct to the best of my know) dge, d meets the California Health&Safety Code requirements. If the food facility <br /> operator fa' o comply with he ditions of this agreement, or if this agreement is modified or cancelled, the <br /> commis s ownneshall notify4l E <br /> f <br /> Signatus?YLu�0 Date <br /> 9. kt[fCD <br /> The commissary is located ir County. The above food facility meets the <br /> commissary requirements in Galifomia 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 />