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P9 61 S4 qD2.01 <br /> SA6JQAQUINEnvironmental Health Department <br /> t COUNTY <br /> Grec3tness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility a Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> Business Name Lic. Plate <br /> # � q9Z 2 <br /> Owner/Operator Name S tyc- -ten 671rou L e <br /> Business Mailing Address 1Do3-7- <br /> City 1 State Ccs Zip 19'fg(9 Bus. Ph. /j bg -14'7'-/ Y5Alt. Ph. <br /> d2++-e P4cl 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 pe Itie' <br /> w <br /> Signature Date—A �-o'y <br /> Commissary Name `�j<<k 'y 6 FA# <br /> Address �`��� E YY1;rCst� cbue Bus. Phone 2c��— q y -�`�`i <br /> City SItitle Zip Q)z o S Owner/Operator Shc e wx Scj i r<; <br /> Check all appropriate services provided: <br /> D Wastewater disposal D 3-compartment sink IfElectrical hook-ups <br /> D Solid waste disposal D Food preparation Toilet and handwashing <br /> Er.Hot & Cold water for cleaning D Store refrigerated food D Potable water <br /> D Store dry food/supplies 3, Overnight parking D Vehicle wash <br /> I, �;� +bv C; r-1 �'�: , ' , hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledge, and meets the Califomia 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, t6$ S <br /> commissary owner shall notify the EHD immediately. 0 <br /> Signature Date N <br /> TM <br /> . O <br /> � O <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 r(l <br /> above commissary. Please notify EHD if the status of their operating permit changes. Y A n <br /> < <br /> RENS Signature DateITl D <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 />