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SA N J OAQ S I N Environmental Health Department <br /> -C(DUNTY—­- <br /> G: . Fie2q 0011L <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 /> • TYyr.be!., how <br /> - •i' <br /> Business Name A) \ Lic. Plate# l(l � <br /> Owner/Operator Name ��N c In U�cw� \9-� Cj� S'_Z .= - <br /> Business Mailing Address �V — <br /> City_a StatQL_Zip25220,.Bus. Ph 4 .3 n 4It..Ph. <br /> I , 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 /> Signature Date <br /> 2. TQ. <br /> Commissary Name, I C ►� fl/ r Q FA# <br /> Address_3�-i 1 m�' n�F L y t Bus. Phone <br /> City Zip 20 Owner/Operator _j a <br /> Check all appropriate services provided: 0 7 <br /> 7 <br /> nN <br /> [3 Wastewater disposal E3 3-compartment sink I�Electrical hook-ups Z <br /> rn <br /> © Solid waste disposal ® Food preparation E'Toilet and handwashing 4 -Z O <br /> Ci Hot & Cold water for cleaning 1"tore refrigerated food 0 Potable water Z Z Z <br /> n <br /> L73 Store dry food/supplies 0�Overnight parking i© Vehicle wash D M n <br /> 4co)fmy <br /> v� hereby state that the information I have provided is current, true and0 > � <br /> correct to the best kn wledge,and meets the California Health &Safety Code requirements. If the food facilitfj m D <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the • ; <br /> commissary owner shall notify the EHD immediately_ <br /> Signature 9 r .� � �,� Date <br /> 3. To - <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 I E 209 464-0138 { www.sjgov.org/ehd <br />