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SAN ;JOAQUIIV Environmental Health Deparr�meffj,i; <br />COUNTY - <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer <br />Complete sections 1 and 2. if your commissary is located outside of San Joaquin County also complete section 3 <br />1. Tobe completed by APPLICANT <br />Business Name &Q-l'�(�`,Q. y 1)a- _ Lic. Plate # #N1 ff/ y <br />Owner/Operator Name 1 fi Vni Q n rl Vn n i r o eL <br />Business Mailing <br />City- StateCEZiPAS2A�LBus. Ph 1-810 Alt. P(1g Lt1S-lbw <br />I. 1(1yni Rodyiva hereby state that the above information is current, true and correct to <br />the best of my knowledge d 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, thepe holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and oenaltiid - l7 <br />Commissary Name <br />Address, `BGG' �" ,zX <br />Date nE5 - 2 <br />BusIPhone L; '//v - 4/S' JG' <br />a i. <br />Owner/Operator I k <br />Check all appropriate services provided: <br />b Wastewater disposal d 3 -compartment sink <br />W <br />Solid waste disposal <br />E3 <br />Food preparation <br />It <br />Hot & Cold water for cleaning <br />M <br />Store refrigerated food <br />M Electrical hook-ups <br />ty Toilet and handwashing <br />G11� Potable water <br />S re dry food/supplies it Overnight parking l�! Vehicle wash <br />����/� hereby state that the information I have provided is current, true and <br />correct to the best of my knowledge nd meets the California Health & Safety Code requirements. If the food facility <br />operator falls to comply with the onditions of this agreement, or this agreement is modified or cancelled, the <br />commissary per shall noti a EHD immediately. <br />Signature Date D/- Or <br />w, �=,,�G• a :x: .kIVE=ML l rt lunsgtctlon outslae 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 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 wenn ninnv nmtphrl <br />