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e(_ 0 S 3 b�Sq <br />SAN, J O A Q U I N Environmental Health Department <br />COUNTY <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 />Business Name1 itr orro Lic. Plate # 7 K�, g E <br />Owner/Operator Name ()j�, j "n / <br />Business Mailing Address_'$"' n 6n L <br />City Eq tsfo State CA Zip 15351 Bus. Ph. L201-6g6o 8337 Alt. Ph. a09 -8S7 -fans <br />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. <br />Commissary Name_ L <br />Phone .2�3`�# . <br />Check all appropriate services provided: r <br />j( Wastewater disposal 133 -compartment sink M/ Electrical hook-ups <br />Solid waste disposal ❑ Food preparation Toilet and handwashing <br />❑ Hot & Cold water for cleaning ❑ Store refrigerated food P(Potable water <br />❑ Store dry food/supplies alovernight parking m Vehicle wash <br />I,Gri�l]7-< hereby state that the information I have provided is current, true and <br />correct to the best of my knowledgeftand 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 ownVshall nojidQlre EHD immediately. , <br />LJ3. 10 btYcompleted by the ENV HEALTH iuricdirtinn niitsida of San _Innnrnin rn <br />The commissary is located in County. The above food facility meets the <br />commissary requirements in Califomia 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 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 i www.sjgov.org/ehd <br />� okoo-co^'t <br />