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ji S A N O A Q U i N Department <br /> Environmental Health De <br /> -----COU NTY- - <br /> Greorriess grows hcn' <br /> w <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 /> f4iA F � Ti3 ;i <br /> Business Name (—OS TU Lic. Plate# E 15 l <br /> Owner/Operator Name 4e c yo r <br /> Business Mailing Address 1 ci Y\ 5 - <br /> City �2-Lc k�Y` State CRZip `)SLR=S Bus. Ph. Alt. Ph. 'zo`ifcj u 7 <br /> I P 1 X-n(j� ZG'0% _-, 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 pen. Ities. <br /> .i Date (.Q ' y ' 2Q <br /> Signature <br /> sr"COMMIS ARY OWNEWOPERATOR <br /> Commissary Name �: �' ? rc' r c C FA# <br /> Address Ic) ' 0 Bus. Phone 2 ,ct <br /> City �1� c ti` `1L _Zip OwnerlOperator <br /> Check all appropriate services provided: <br /> [) Wastewater disposal d 3-compartment sink M Electrical hook-ups <br /> Of Solid waste disposal C3 Food preparation 13 Toilet and handwashing <br /> P Hot & Cold water for cleaning Ll Store refrigerated food Potable water <br /> L] Store dry food/supplies bile-Overnight parking Vehicle wash <br /> I, NAa hereby state that the 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 cancelled, the <br /> commissary owner shall notify the EHD immediately. 21� 5 <br /> Date <br /> Signature <br /> � �r <br /> 9Nu HEALTH 'urisdiction outsi a of Sain- <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. 31 i LI <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue l Stockton, California 95205 1 T 209 468-3420 l F 209 464-0138 1 www,sj`g''o++v.org,'ehd <br /> PC I "I 01-4i <br />