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k'1? 05 � 16 (131U1 <br /> S A N s,J O A Q U I N Environmental Health Department <br /> Cc1l) NIY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ,,, Caterer <br /> compipte -tzections 1 and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. Tolbe,co.Ilplefiedl ��� <br /> Business Name__ dc.i 174i; /L _Lic. Plate# <br /> 48 <br /> Owner/Operator Name - <br /> Business Mailing Address _ orhil'N City j`� State CIO Zip � 2'CBus. Ph9; — �42 P <br /> 1, L �) .! ` 014� 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 /> Safely 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_-- 1 .1r� N Date 77-3 <br /> 2. Tobe 00MA, Wb, R cEO, } -�- <br /> Commissary Name_L FA# iQ017 <br /> Address , Oil '}-�f}r ►g r�! _ Bus. Phone 201 - 712r 544e <br /> M` City LEL, Zip Owner/Operator f-.�V.[— <br /> Check all appropriate services provided: <br /> Wastewater disposal ❑ 3-compartment sink Electrical hook-ups <br /> Solid waste disposal ❑ Food preparation Toilet and handwashing <br /> ❑ Hot & Cold water for cleaning ❑ Store refrigerated food P(PPotable water <br /> ❑ Store dry food/supplies Overnight parking ar Vehicle wash <br /> I, _ S��VIC :j4j .:fF:-- , hereby state that the information I have provided is current,true and <br /> correct to&ke 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 hall no ' e EHD immediately. <br /> S►gnature _ ��, Date j7/ 2- <br /> _completedl�b Wt -- ,, fiil�I 0tidea ai�i Cha: <br /> The commissary is located in County. The above food facility meets the <br /> commissary regwrarrionts In California Health & Safety Code. The above checked services are available at the <br /> above commissary. Please notify FHD If tho statue of their operating permit changes. <br /> REHS Signature -- -- - �- — — _.Date_-__—_ <br /> 1868 E. Hazelton Avenue I Stockton, Callforrda 052051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />