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�pUIN <br />' SAN _ OAQUIN Environmental Health Department <br />COUNTY— <br />°911r 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 <br />Business Name <br />Owner/Operator <br />Business Mailing <br />Plate # <br />Ph, ,)0g0/570a_XaD l Alt. Ph. �,qogy701203 q <br />I, , hereby stale that the above information is current, true and correct to <br />the best 6f 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 />revocation and penalties. <br />2. To be completed byCOMMISSARY OWNER/(O' P'ERATOR <br />Commissary Na e U Nw FA# <br />I - � 1\ /Ii Vl Af­,0 n _1 <br />City V �( JAN WAA 11, jA ' Zip t i'J' Owner/Operator 1-1 I -M LUV 16 U I I LZI T l <br />Check all appropriate services provideed:� <br />�Xwstewater disposal ❑13c mpartment sink E3 Electrical hook-ups <br />olid waste disposal e' Food preparation M'foilet and handwashing <br />U Hsot & Cold water for cleaning ❑ Store refrigerated food ❑ Potable water <br />❑ ?j 6re,�ddry1 ffo'o/d,/su)�plies'n E3 Overnight parking E3 Vehicle wash <br />1, a/1 t1 lel l�©� 1c7/ -,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 <br />r shat) n tify the EHD immediately.) /� <br />Sig�%nature IY \ Date -7!/ `"' Z_Z_ <br />13. To be completed by the ENV HEALTH iurisdiction 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 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />