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SAN JOAQUIN Environmental Health Department <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 /> 9; To be completed bVAW <br /> 411CANT <br /> Business Name r Lic. Plate# <br /> Owner/Operator Name <br /> Business Mail' g Address klo;zll Dr <br /> City lAreft Statek p 4?-S^iyj9 Bus. Ph.�?M�?ft-40 X -Alt. Ph. <br /> I, 11,1141 . hereby state that the above information is current, true and correct to <br /> the best of my owledge 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 discontinu d, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and pe It' . <br /> Signature Date <br /> 1 To be completed by COMMISSARY OWNER/OPERATOR- <br /> commissary Name i/IW A J5 5(f Y1 AZ'K<z FA# <br /> Address Z�2(J S Bus. Phone L%0 7 2 Z y 933 Y <br /> City 40a/ Zip 0119270 Owner/Operatorflly44mtrw_ <br /> Check all appropriate services provided: <br /> M/GVastewater disposal U4_`compartment sink M'Electrical hook-ups <br /> Q Solid waste disposal PI#Wood preparation EP/Toilet and handwashing <br /> ILQ Hot& Cold water for cleaning i/6toore refrigerated food ID/F table water <br /> q/S`tore dry food/supplies a Overnight parking 'Vehicle wash <br /> I, Azi-CGvL- 64k*w 5:S , 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 notify the EHD immediately. <br /> Signature �.�6L 4 fAe Date ld - - 22 <br /> 3: To be com leted by the ENV HEALTH jurisdiction outside of San Joaquin Co. <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 1 Stockton. California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />