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SAN.JOAQUIN Environmental Health Department <br />—COUNTY— <br />Greatness grows here. <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 com leted b APPLICANT <br />Business Name -� 61 T� W G 5 Cir 1 1 1 Lic. Plate # <br />Owner/Operator <br />Business Mailing <br />0l2Ll I-tZS`ttAlt. Ph <br />I,I'S VM 1,_-liCA V I �ULU , 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 />Commissary Name L--� i-' ZA-e mA <br />Address lG2(i S-S:tt^CLxN\Q,' k0 Bus. F <br />City I -C& Zip aSZLC Owner/Operator_ <br />Check all appropriate services provided: <br />Wastewater disposal 9( 3 -compartment sink ;q Electrical hook-ups <br />Solid waste disposal )!1 Food preparation Toilet and handwashing <br />Hot & Cold water for cleaning 0 Store refrigerated food Potable water <br />Store dry food/supplies J211 -Overnight parking Vehicle wash <br />I, 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 to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall n tify the EHD immediately. <br />Signature Date fy-O'l qi az7 <br />W1 <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 />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />C�nrctGl <br />