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SAN.JOAQUIN Environmental Health Department <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 N <br />n <br />Plate# Y49 Ly 11 <br />Owner/Operator <br />Business Mailinc <br />CityC,2,�L 1._State4aZip jBus. Ph <br />. _,1b g33/4/ - It. Ph. <br />I, , 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 />Commissary Name AZfr!_�<= FA# <br />Address62G '5 .Sac�uAs -o+8 Sa- Bus. Phone&IJ Va`✓-$33V <br />City L00i' Zip isZyo Owner/Operator Al! dJko ►o GCs�dL <br />Check all appropriate services provided: <br />Mastewater disposal 12 3 -/compartment sink EVElectrical hook-ups <br />olid waste disposal ® Food preparation Qr 'fcilet and handwashing <br />/Hot & Cold water for cleaning Cd" Store refrigerated food 0 /table water <br />M Store dry food/supplies t 13 Overnight parking ®'Vehicle wash <br />I, yr % SSArY ff 2iC4_ , 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 owner shall notify the EHD immediately. <br />Signature_ / Date oC <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 />1868 E. Hazelton Avenue i Stockton. California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgcv.org/ehd <br />