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REHS Signature <br />1865 E Hazeiton Avenue Stockton, California 95205 I 1 209 468-3420 I F <br />SANI.JOAOUIN <br /> Environmental Health Department <br />^4 T • <br />COMMISSARY AGREEMENT <br />comedv.,9 <br />Mobile Food Facility • Caterer <br />Businesn Name <br />Cf:1------ <br />„ is 0 c„„,piere seaton 3- <br />, I'vt-h°n•C ! and 2 If your CT) fSSaty <br />is loathe outseo ol San Joaquin Counri <br />°Yvner/Oporator <br /> NaLmae. bajAtigana Ipsoitt—ick <br />4u 8572 <br />Business 11.4atling Addres <br />la_ lid. ialtazquez _ <br />Lic. Plate <br />CitySt f% r , b4._ —,_,..„ A <br /> <br />d„,. y la Vazque —‘74 a • <br />Ait Ph. 2O9)7:746580 <br />comnas . ncl san jcwo,in cmntiy Enwocurerital Health Department (EHD) reowiernehts. it°rn <br />thelauci-iseoictt.tnt:eit <br />,siaryariad dpiscoarsittiinued. the <br />na agtoo to uttior my approved commissary in accordance with Calif <br />ofl <br />4...1k...4% Ltate_Zip9AZALLF_Bus Ph <br />Safety Code, kn°wIlidge <br />_ Z . hereby Mate that the above information is current.. Uue and _ .—_—_—_-- <br />Signature <br />permit home( must notify the EHD. Failure to rotity this office may result in <br /> perm <br />revocat <br /> cla_udia Vazquez Date <br />121 To be completed by COMMISSARY OWNER/OPER!%_71:_g_g____ ___ — --- <br />Commissary Name -1 4 <1-' I 1 <br />Address 1-6%c ig S. Al /21-07 7 Bus. <br />City 611--e bpg Owner/Operator <br />Check all appropriate services provided: <br />O Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for dew:ling <br />CI St e dry food/sup ies emight parking <br />I. i 70ykk.r, , .0,, , L • 1 . hereby state that the information I have provided is current, true and <br />correct to the best of my owledge. and meets the California Health & Safety Code requirements. If the food facility <br />operator fails toçip4y with the conditions of this agreement. or if this agreement is modified or cancelled, the <br />commissary owner tall iffy the EHD immediately. <br />Signature <br />[3.m 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 />COrnmrsSary requirements in California Health & Safety Code. The above checked services are available at the above commissary. Please notify EHD if the status of their operating permit c.hanges. <br />FAtt <br />3-compartment sink <br />Food preparation <br />Store refrigerated food <br />Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />Vehicle wash <br />/ <br />Date