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SAN-JOANN Environmental Health Department <br />_ .. <br />COUNTY— <br />COMMISSARY AGREEMENT <br />Mobile Food Facility + Caterer <br />Complete sections 1 and Z If your commissary is located outside of San Joaquin County also complete section 3. <br />1. To-bepoMpliqW.by APPL[GANT <br />Business Name ia[ -j Z" _Lic. Plate # <br />Owner/Operator <br />StateC4 Zip`�S �G" BUS. Phk, - ��Ii'//7G' Alt. Phi.) <br />I, hereby shite that the above information is cumant,_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 a/V)enaltiee. <br />Sion4ACk'- Date <br />2s To be Wm feted -b COMMISSARY OWNERIOPERATOR 'r <br />Commissary Name <br />Address age E v a tJAa Bus. Phone oqpc� �tLl �i �� Gl s 7® <br />rih 0 t r iclwAn Zio OIC ZoS Owner/Ooerator C 1n; 0 Acne,-vt <br />Check all appropriate services provided; <br />Wastewater disposal :rY 3 compartment sink <br />epoiid waste disposal 0 Food preparation <br />Hot & Cold water for cleaning [3 Store refrigerated food <br />0 Store dry food/supplies i d�'Ovemight parking <br />t EI til hook ups <br />T 'let and handwashing <br />@� /VehicP�ehiclewater <br />�`le wash <br />1, hereby state that the information I have provided is current, true and <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. if the food facility <br />operator fails co ply wish the conditions_¢i'this agreement, or if this agreement is modified or cancelled, the <br />commissaryvmer shall notify th�E�iB�rifmmediatefy <br />3. TO completed by :.the €IVU :HEALTH 'urtsc3icfion atttsicle ofisart,ioa _ frim Cts. <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 <br />1668 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 4640138 1 wwwsjgou.orgfehd <br />