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JAN JOAQUIN Environmental Health Department <br />---COUNT Y— <br />_. Greotness yrotys here. <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 />1. To be com <br />Business Name <br />Owner/Operator <br />Plate # <br />Business Mailing Address so"7i_) P11 -64/1Y7 sr <br />CiID Statef::;A ZiP15'X�, Bus. Ph.,�Oq L%6r/ri Alt. Ph. <br />1. ZOA Q OU 12-+g3 , 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 />/Y) <br />Signature Date i % / �- <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name P t C k Yl/ ter' a 9 c E_ CAF A-" FA# <br />Add <br />Check all appropriate services provided: <br />❑ Wastewater disposal ❑ 3 -compartment sink <br />❑ Solid waste disposal ❑ Food preparation <br />❑ Hot & Cold water for cleaning EI-t8re refrigerated food <br />❑ Store dry food/supplies i3��ernight parking <br />Phone tea- 0Wf'-l-7u4 <br />CkElectrical hook-ups <br />G-TbRet and handwashing <br />❑ Potable water <br />O Vehicle wash <br />I, , 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 , ncr-m �-,.,r r' C:�• Date <br />1 To be completed by the ENV HEALTH jurisdiction outside 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 www.sigov.org/ehd <br />awn <br />Oa'T. <br />0r,�Z <br />.qmO <br />O '" O <br />Z <br />Aim <br />•yy > <br />m n <br />3 <br />