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SAN JOAQUIN <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> <br />Lie. Plate# t\/(J CZ <br />'■-r L-'i -• <br />Date <br /> r Joaquin Co <br />REHS Signature Date. <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. Piease notify EHD if the status of their operating permit changes. <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Business Name <br />Owner/Operator Name <br />vPy-5 $ /VI rn yi. <br />Business Mailing Address fl-Ccy *26 <br />City StateZip 95?^ Bus. Ph.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 />S i g n a tu re <br />_FA#_____________________ <br />Fg^7z) <br />iS^^iectrical hook-ups <br />i^-yoiiet and handwashing <br />Zk^otable water <br />Sy7ehicie wash <br />, hereby state tharthe information I have provided is current, true and <br />correct to the best of my knowledge, and meets the California 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 canceiied. the <br />commissary owner shall notify the EHD immediately. <br />Signature <br />J u a-r/TX <br />Com m issary Name r f <br />Add ress S Bus. Phone j <br />City Zi p Owner/Operator <br />Check all appropriate services provided: <br />’gP/Vastewater disposal 2?^compartment sink <br />ZJ/^olid waste disposal (S^Food preparation <br />TjA-'riot & Cold water for cleaning Q^Store refrigerated food <br />il^^tore dry food/supplies gS^Overnight parking <br />I, <br />'S68 E. Hazelton Avenue Stockton. California 95205 I 209 458-3420 <br />Date <br />209 464-0138 v.'W.v s,cov.org. =~c