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SAN.9JOAQUIN Environmental Health Department <br /> r' --C O U N T Y----- <br /> . ' Greoeness r�rOw*, i�nre. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility * Caterer <br /> Complete sections 9 and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br /> Business Name '7 Lic. Plate# J N75 33 <br /> Owner/Operator Name <br /> Business Mailing Address_ 7 ,� �+� � 4 <br /> City StatejZ&Zip 3 v Bus. Ph.(323 )`? -03 I Alt. 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 enalties. <br /> Signature Date d <br /> Cormnissa Name / r)r i c en.4 1 FA4 <br /> Address pr Sus. Phone <br /> city 4m CO,,�On Zip OwnerlOperator 24Ws }moo r) <br /> Check all appropriate services provided: <br /> Wastewater disposal ,l -3-compartment sink "Electrical hoof:-ups <br /> 4^Solid waste disposal 6 ' Food preparation C�-Toilet and handwashing <br /> fff Hot&Cold water for cleaning ' Store refrigerated food dr Potable water <br /> €'Store dry food/supplies Overnight parking 'Vehicle wash <br /> + hereby state that the information I have provided is current,true and <br /> correct to the eest 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. <br /> Signature �Da <br /> Lz' <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Cade. 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 i T 209 468-3420 I F 209 464-0138 1 vnxw.sjgov.orglehd <br /> �QIGOD5g3 <br />