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SANb-JOAQUIN Environmental Health Department <br /> —COUNTY— <br /> "9a`: Greo�r.=.ss grsims r��:'_. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections land 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To:bevom leted-b AnPPLICANT <br /> Business Name 1� �— {� �— Lic. Plate# <br /> Owner/Operator Name <br /> Business Mai--ling Address <br /> Cityall , State Zip t 7. Bus. Ph.a09- 77S1-G5' _ Alt. Ph.- 0,9 Cv 99 -S 5'a7U <br /> 1, N-4U&-4 �, VG a U P-Z hereby state that the above information is current,true and correct to <br /> the best of my knowledgea d ager ree 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 disc tinued, the permit older must notify the EHD. Failure to notify this office may result in permit <br /> revocation a pe ties. <br /> Signature �� ��JC f/t / Date <br /> �— <br /> �. ;t:bCom.leted:b: COMMISSARX-'0 l NE-A/O.PE�AT O� <br /> Commissary NameGt ALFA# <br /> Address Am 0� I Bus. Phone✓dI 1)el 1-1lP V//-� Lf S 7C9 <br /> City Ur.- Zip qS (',C- Owner/Operator • �t .� �/ �� ye�2c1 � <br /> Check all appropriate services provided: <br /> 1A Wastewater disposal a 3-compartment sink 16 Electrical hook-ups <br /> d Solid waste disposal 0 Food preparation 0 Toilet and handwashing <br /> 10 Hot & Cold water for cleaning 0 Store refrigerated food 10 Potable water <br /> re dry food/supplies Overnight parking [ Vehicle wash <br /> 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 ditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary wrier shall notify I)} zHD immediately. <br /> Signature_ 77"&e-k a--4 L:Z� Date <br /> 3..To be coria°)eied p the,ENV4 . udsdi, Co <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements iwoalifomia Health & Safety Code. The above checked services are available at the <br /> above commissary P eas tify EHD if i a status of their operating permit changes. <br /> REHS Signatur Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />