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SANJQAQUIN Environmental Health Department <br />---COUNTY- <br />hrcatness grows liter. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility • Caterer <br />sections 1 and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br />Business Name �/'/ `J Lic.Plate #g82V_ IZ�� <br />Owner/Operator NameI�- <br />Business Mailing Address �I� Q l�wi�C� c too -MQ -- <br />city 5+_61 �-Oet ttate� AZip��Bus. Ph. %bl'G) Cl+1/-45Z4Alt. Ph. <br />civ Y r ✓ 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 discontl -, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and ceoaltiea..' <br />Signature /��Sj —�-� _ Date I Z_/Z. 3/2 <br />2 <br />12. To Oe-ceniipleted by COMMISSARY OWNER/OPERATOR I <br />Commissary Name 1 FA# 2De1"Vi I -/(Alc/ <br />Address Bus. Phone 209 SLS 1 1753 <br />City zip Owner/Operator�`5pX, <br />Check all appropriate services provided: <br />'Wastewater disposal R 3 -compartment sink PYElectrical hook-ups <br />0' Solid waste disposal 13 Food preparation a Toilet and handwashing <br />t_. U Hot & Cold water for cleaning 0 Store refrigerated food 0 Potable water <br />0 Store dry food/supplies 0 Overnight parking 0 Vehicle wash <br />1, 1r »tl AEU C, , 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 gwrter shall notify thVHD Immediately. <br />13. To be completed by the ENV HEALTH iurisdictlon outside of San Joaquin Co <br />The commissary is located in _�� C_N;S?GUS 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 [Weltatus of their operatin ermit cha <br />REHS <br />I 9 p ngas. <br />I- 2_27> .201-5 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209468-3420 1 F 209 464.0138 1 www.sjgov.org/ehd <br />/r. -'I <br />1 ' <br />