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S Q 7 ` ``' Environmental health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete sections i and 2. If),our commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be competed by APPLICANT <br /> (� t <br /> Business Name (},i )L 1L1 tNC,rkic. Plate#"t. L� a <br /> t � ' !l L � _. <br /> Owner/Operator Name <br /> 1 ��t�iCi t <br /> Business Mailing Add ess �( <br /> r, n State Zip'..'L'i C. Bus. Phc)I Z -� I 2�11 Alt Ph-'N li_' F;�i d �t • <br /> 1, F, 1t i Cj 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 io notify this office may result in permit <br /> revocation an nall"s. <br /> } <br /> Signature 1 t'� i1 /iC � Date C T <br /> 12. To be completed by COMMISSARY OWNER/OPERATOR <br /> Comm ,hissary Name' c J � ° FA# :A- 93 1?00(� <br /> Address � b�1J Pi✓ S-jf— Bus. Phone ILE- 9(417-7170 <br /> City_ �� Zip YSS1 Owner/Operator of Ppt.- <br /> ChE-Cit all appropriate services provided: <br /> q Wasteviater disposal _ 3-compartment sink '/ <br /> 1' Electrical hook-ups <br /> Solid waste disposal -� Food preparation � � <br /> �/ {//tpilet and handwashing <br /> 0 Hot&Cold water for cleaning ` Store refrigerated food Y <br /> 13 Stored to /P table water <br /> °�sl°Pp'eOvemight parking (Vehicle wash <br /> I. �ithVld41 W <br /> wrteCtto the ,hereby state that the information I have provided is current,true and <br /> best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> oparator fails to Comply With the conditions Of this agreement, or if this agreement is modified or cancelled, the <br /> commissary ow er shall notify the F_HD immediately. <br /> signature�2 � <br /> 3.To tie COM lett b me ENV HEALTH •urisdiction outside of San Joa uin Co. <br /> Themrt" <br /> cossary is located in <br /> COMmiasary r uire <br /> e9 mems in California Heall 8 Saf COunty. The above food facility meets the <br /> above commissary ery Code. The above checked services are available at the <br /> notify E It{rye status of their operatin <br /> RENS Signayna (�]/,,� 9 permit cha S. <br /> Date I <br /> t9Sa E.Haaekon Avenue I Stockton,California 9s2oe <br /> I T 209 469-3420 1 F 209 464-01 8 sj v.org/ehd <br />