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S A N.5J O Q Q U I N Environmental Health Department <br /> COUNTY --- <br /> . <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San <br /> tt Joaquin County also complete section 3. <br /> A t 4 <br /> 1. Tobe.com -1etedbkAF0I '`M `�-� <br /> Business Name `/(-t r / w Lic. Plate#ftk <br /> Owner/Operator Name I J <br /> Business'Mailing Address 14 <br /> City State +o Zip S�Z Bus. PhYAJA. P . <br /> 1, f KO(,J/4}) J C'� r/I f'� 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 /> Signature J� Date <br /> 2. T03b� bJ-rr�1LI7l�dlt}0 :? ' r u' <br /> Commissary Name_, FA# 00,2 7 4 9� <br /> Address_� t 'Hiq <br /> Tnj ��_ Bus. Phone .201 - �I Z��to �� <br /> City L4:4"o Zip Owner/Operator j-,krVe_ 33oirvyl IL <br /> Check all appropriate services provided: <br /> Wastewater disposal 13 3-compartment sink Electrical hook-ups <br /> Solid waste disposal 17 Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning 0 Store refrigerated food [P(Potable water <br /> ® Store dry food/supplies Overnight parking Eir Vehicle wash <br /> 1, vY1S Lk 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 own all no' e EHD immediately. <br /> Signature Date 7 2- <br /> 3. To b corn leted b sIdekofl <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 i F 209 464-0138 1 www.sjgov.org/ehd <br /> Ti r1/�L1•. O/`t_4-S tcO -6,(1 ck n X C) <br />