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" k &J | O & MU | W <br /> � /4Y� j�l��UUi [� <br /> Environmental Health Department <br /> - <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility, ` Caterer <br /> Cornolete sections 1 arid 2. It your commissary is located outside of Sari Joaquin County also complete Section 3. <br /> 1-11. To-be cqmplete.d by APPLICANT <br /> Aj I wACL 11;i L(NL6 (z hereby state that the above information is current, true and correct to <br /> the best �Fm y-knowledge and agree to utilize my approved commissary in accordance with California Health 1^1 <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD} requirements. If the use u/ tne <br /> commissary iodiscontinued,the permit holder must notify the EHD. Failure tonotih/this office mavresult|npen-` <br /> revocation and peno|Uea <br /> Signature 000 12 <br /> Z. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name California Catering Food Service & Supply F <br /> Address Bus, Phone <br /> Stockton Zip —Owner/Operator <br /> ,heck a|| appnophmteservices provided: ` <br /> ��VVao��vvm�erdiapume| 43'compa�mentoin� 00 Electrical hook-ups <br /> ' . <br /> Q� Sohdwaste disposal Food preparation Toilet and handwaohmg <br /> Hot& Cold water for cleaning Store refrigerated food Et Potable water <br /> Store dry food/supplies � Overnight ki 14 Vehicle wash <br /> �. <br /> hereby state that the information !have provided\acurrent, true and <br /> -csrect to the b4_t 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 ogmoment, or ifthis agreement is modified or cancelled, the <br /> .,ommissary owner Unotji Hi mediately. <br /> Z:griature Date 17, <br /> 3. To be completed-bY thOAMMULTH kith <br /> 'The commissary islocated in County. The above food facility meets the <br /> r"mnniooaryrequirements /nCalifornia Health & Safety Code. The above checked oanvioaa are available atthe <br /> above commissary. Please notify EHD|fthe status oftheir operating permit changes. <br /> REHS Signature Date <br /> �8G8E. Hazelton Avenue( Stockton, California Q52US1 T 209468'34201 F 209 464-0138 !wwmv.sjguv.org/e»U <br />