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~ <br /> —S—A ]O AUK N Environmental H eaU � � �, °, <br /> * <br /> [0UNTY- (~ EmV0Q) <br /> Gneotnes� grows hc'" <br /> NOV � � ���� <br /> ~ w ��u� <br /> COMMISSARY AGREEMENT /"N"XRONAWNTAL "EALT11 <br /> ?ko��K <br /> MOhi|2 Food Facility o Caterer "'�'l)"kRTlNIENlr <br /> Complete sections Yand 2. If your commissary is located outside m`San Joaquin County also complete section 3. <br /> IOW&�Y:APPLICANT <br /> Business Name C,) LJ <br /> Business Mailing Address <br /> Ci i '620Bus. Ph L Ph. <br /> | hereby state that the above information iacurrent, 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. |fthe use ofthe <br /> commissary iediscontinued, the permit holder must notify the EHD. Failure tonotify this office may result inpermit <br /> revocation and penalties. <br /> -� <br /> Signature Dote z* <br /> MISSARY OWNER/OPERATOR <br /> Cit Zip OwnerAperator h.1' 6jll�� /2' <br /> Check all appropriate services provided: <br /> Ej Wastewater disposal C9 3-compartment sink VE|ecbioa| hook-upo <br /> m� <br /> Solid waste disposal 61 Food preparation El Toilet and hQOdxvaShing <br /> Hotfk Cold water for cleaning E3 Store refrigerated food ' Potable water <br /> E3 Store d[VfOOd/8UDp|i88 U Overnight parking M}Jehide xY@Sh <br /> |. . hereby state that the information | have provided iocurrent, true and <br /> correct to the best of my knowledge, and meets the California Health &Safety Code requirements. |fthe food facility <br /> operator fails to comply with the conditions of this agroement, or if this agreement in modified or onnce||ed, the <br /> commissary h U d <br /> Signature Dat <br /> the ENV HEALTH jurisdiction outside of San Joaquin <br /> The commissary iolocated 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 EHOifthe status oftheir operating permit changes. <br /> REHS Signature Date <br /> 1O08E. Hazelton Avenue | Stockton, California 95205 | T 20S488-3420 | F 2894S4-0138 | vm^ow.oj0ov.org/ehd <br /> c� <br /> -/ <br />