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SAN JOAQUIN EnArranmenW Heafth Department <br />- <br />COUNTY -- <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer <br />Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Business Name Lic. Plate #cg c <br />Owner/Operator Name zkmb Tom` - <br />Business Mailing Address <br />City M(,kUNJ State rAzio' q 57-661 Bus. Ph. qi - It. Ph. <br />I, WI 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 to notify this office may result in permit <br />revocation and penalties. r <br />Commissary NameSl.1.ilivl/ CA <br />211Q�rtcf�i�l(eSFA# <br />�_-- Iy o— <br />Address 4t4O �S- N, - r T N��k4 --- Bus. Phone f% Ii�G(n0, �CIO' <br />�`��':1.fY�-f�j/I'�.�h <br />Check all appropriate services provided: _ <br />Rr Wastewater disposal WS -compartment sink <br />R/Solid waste disposal <br />V'Food preparation <br />W F-lectrical hook-ups <br />V Toilet and handwashing <br />Euo"Hot,& Cold water for cleaning M Store refrigerated food W. Pptable water <br />218nto�re 'dry food/supplies Overnight parking *F Iehkcle wash <br />1, int' 1(; 1�4 221 1] , 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 />commiss ner shall notify the EHD immediately. <br />-•-- -- Ihis '�- }D O - 14-Z>_ <br />. To be comoleted'bv the ENV HEALTH jurisdiction ouitside 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 />RENS 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 />