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Lie. Plate # <br />Date. <br />Zip <iy5£5 Owner/Operatbr. <br />^2^0CXD\ <br />A <br />SAN JOAQUIN <br />-----COUNTY------ <br />Greoireji <br />d' 3-compartment sink O Electrical hook-ups <br />tif Food preparation Toilet and handwashing <br />Store refngerated food Notable water <br />(f/Overnight parking DK'Vehicfe wash <br />. hereby state that the Information I have provided is current, true and <br />If this agreement is modified or cancelled the <br /> '1/ 2-4/____ <br />Environmental Health Department <br />HECD <br />*4?D25 <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Complete sections 1 and 2 If your commissary ts located outside of San Joaquin County also complete section 3 <br /> <br />1. To be completed by APPLICANT <br />Business Name V" <br />Owner/Operator Name ‘'Tb {~ Q, *''•¥^0 i "2- <br />Business Mailing Address jtLf >£V\ck g € —------------------------------- <br />o StateC A zip^5^°4 Bus. Ph--------------------------- <br />I 't~Z- . 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 Hea'th & <br />Safety. Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of tne <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,Da e —----------------------------------- <br />- 2- to be completedJy COMMISSARY OWNER/OPERATOR <br />Commissary Name ----------------------------------------------------------------------- <br /> Address,,, Bus- phone,XUQ. L <br />City -Z'P- WfV____Owner/Operator., ----------- <br />Check all appropriate services provided <br />Wastewater disposal <br />Q Solid waste disposal <br />df Hot & Cold water for cleaning <br />(Sfstore dry food/supplios <br /> LTrecuTih^^my knowledge, and meets the Culiforma Health & Safety Code requirements. If the food facildy <br />operator falls to comply with the conditions of this agreement, or i <br />commissary owner snail notify the EHD Immediately. <br />Signati.. P^U <br />3. To be completed by^e^NVj^ALTHjunsdipUpn'^utsW Sarulpaguin Co. <br />Th,. '■-county. The above food feeiWy moth, 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 ponnit changes. <br /> 7/ A ------— | <br />1868 E. Hazelton Avenue | Stockton, Cabfomia 95205 | T 209 468-3420 | F 209 464-0138 lwww.sfflov.org/ehd