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'SANJOAQUIN Environmental Health Department <br /> —COUNTY— <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT - <br /> Mobile Food Facility * Caterer <br /> Complete sections I and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> Business Name S(D ?\40+ 6LC_05 LL-C- Lic. Plate# <br /> Owner/Operator Name scpIy� cl-k-� <br /> Business Mailing Address W VV1af-UVk1 4V8_ <br /> City S+0Gk+6V1 State4�Zipg5 <br /> a0313us. Ph. 96q 8TK0q3A6Ph. <br /> 5�?A24,4+ CILL&I/ hereby state that the above information is current, true and correct to <br /> the best of my knowledge and airee 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. <br /> Signature �G Date <br /> R"s' 7 ° 04letedWw' <br /> Commissary Name FA# <br /> Address 1o70 Bus. Phon&q <br /> city W&k —Zip 2 l0 Owner/Operator 01 <br /> Check all appropriate services provided: I <br /> Wastewater disposal 0 3-compartment sink Electrical hook-.ups <br /> Solid waste disposal 0 Food preparation Toilet and handwashing <br /> Hot& Cold water for cleaning Store refrigerated food Potable water <br /> Store dry food/supplies gOvernight parking Vehicle wash <br /> 1. �ftftffiQT� A-1-4f rl) _, hereby state that the information I have provided is current, true and <br /> correct to the best&+y 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 owners all n ify the EHD immediately. <br /> Signature Date 0(0(G7 4L <br /> 1wo I <br /> X'�T <br /> 1:01 TMV #Np'!eWffiftffl 0, 1111M <br /> 0- <br /> OWN <br /> Xlk 9! <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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />