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®� ILI �3 <br /> SA N FjJ OAQ U I N Environmental Health Department <br /> COUNTY— <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 /> � � <br /> 1. To be com feted,b; ,APR��IIO <br /> Business Name f W-47 S _5,C_)31-j4 Lic. Plate# U t' b 2 S77- <br /> Owner/Operator Name N\G,-( C)CV cn <br /> Business Mailing Address c ` 1 C <br /> City �� StateC/V Zip� J 3'0 Bus. Ph.'�O�, -"4 bC' "`1 b�_-'Alt. Ph, <br /> 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 /> :rte � Date <br /> � 2 <br /> Signat <br /> 2. To,be color l` Bbl, COlkl liSS 1R: F` aME.. 1!( :P,EI ATOR a 1 <br /> Commissary Name I,, FA# 0027 f9 <br /> Address_�,� _ �}r 1q r�- Bus. Phone 201 - 77 <br /> City +r44 Zip q g g'Owner/Operator '.2V� <br /> Check all appropriate services provided: <br /> Wastewater disposal ❑ 3-compartment sink El Electrical hook-ups <br /> Solid waste disposal ❑ Food preparation Toilet and handwashing <br /> ® Hot & Cold water for cleaning ❑ Store refrigerated food LP(Potable water <br /> ® Store dry food/supplies Overnight parking @(Vehicle wash <br /> I, -t ( vY1Shereby state that the information I have provided is current, true and <br /> meetthe California Health&Safety Code requirements. If the food facility <br /> correct to the best of my knowledgeind me <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 /> Signature Date <br /> 4 <br /> 3. To b :com leted:ibt '.' W� , risliCt<ano.utsid.e�of S'az;J.o, ttr °��d: <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 1 F 209 464-0138 1 www.sjgov.org/ehd <br />