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,RO � <br /> sLi-� ��- <br /> SAN J OAQU I N Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> � <br /> . <br /> T0.� <br /> Business Name �(ti5 1.J��e,��c � Lic. Plate# 2 <br /> Owner/Operator Name ��« �,� <br /> Business Mailing Address NeF A�--SD <br /> City Usc StateZip �1��2� Bus. Ph(jA 7 {Z4Y-1- Alt. Ph. <br /> I, hereby state that the above information is current, true and correct to <br /> the best of 0Ky 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 /> Signature Date <br /> 2. To be compieted by COMMISSARY OWNER/OPERATOR <br /> Commissary NameFA# I <br /> Address dal/ Bus. Phone �ZC,7/ Z Z41_ ?1335' <br /> City 4D 0 ' <br /> Z Zip 'j5 Z f'e Owner/Operator �— <br /> Check all appropriate services provide_d� <br /> wastewater disposal 0/3"-compartment sink Electrical hook-ups <br /> o id waste disposal Fl�ood preparation /�oilet and handwashing <br /> Hot & Cold water for cleaning 'Store refrigerated food 2—Potable water <br /> QStore dry food/supplies Overnight parkingVehicle wash <br /> I, ,4hereby 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 � — Date 23 <br /> 3. To be completed by the ENV HEALTH jurisdiction ou ..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 /> '868 E. i;azeiLc77 Ave^:,:e Stockton, California 95235 T =68-3423 F 209464-3'38 ww•✓.s yo _ e� <br />