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SANAOAQUIN <br /> <br />Environmental Health Departmer <br />COUNTY <br />• <br /> h r,r C. <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 />.441);torty,, z;:i;V11;;Ati:" <br />Business Mailing Address 10/3 6 (810 ,p <br />City ---V-cA ki--p State 4 Zip / cci Bus. Ph. Wei- ZOO - b(y a Alt. Ph. 7E)‘7.- E 71- t/7 <br />the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br />1, , hereby state that the above information is current, true and correct to <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 />Signature Date 1 <br />revocation and pe ies. <br />41— <br />2. Tabe-cor,np :0100600040NIER40 „:4TORIPitt, <br />Commissary Name L+,1t—spe F ,o 4 pirlz_n FA# oo,/ 7 493 <br />co od r _ Bus. Phone Eaffi - % Address <br />City 144:14 Vire)e Zip 9_6 ;300wner/Operator '5F-RA(0,— fternarp... <br />Check all appropriate services provided: <br />Eil(Electrical hook-ups Ed Wastewater disposal 0 3-compartment sink <br />Solid waste disposal 0 Food preparation El-Toilet and handwashing <br />0 Hot & Cold water for cleaning 0 Store refrigerated food EP/Potable water <br />0 Store dry food/supplies IjOvernight parking l2a/ehicle wash <br />I, Sfgadre_I-CAPOS-C— , hereby state that the information I have provided is current, true an <br />correct to the best of my knowledge and meets the California Health & Safety Code requirements. If the food facilip <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, th( <br />1- difr e END immediately. commissary own hall no <br />Signature AZ _ 'Ili Date/ <br />3. To b completedlor <br />The commissary is located in County. The above food facility meets th4 <br />commissary requirements in California Health & Safety Code. The above checked services are available at tht <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />REHS Signature <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/elic <br />Business Name ,e)e <br />Owner/Operator Name )0.41 <br />1. To be completechbOEI , <br />Lic. Plate #_40-97 <br />Date <br />/...• Alb e <br />