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Commissary Name <br />Address <br />City <br />r <br />zgt-,,ZCfgt <br />4 <br />' •t2I ••0 <br />SAN ,JOAQUIN Environmental Health Department <br />COUNTY <br />Greatness 91'0WK <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 <br />3. <br />Business Name C\AL, t <br />Owner/Operator Name <br />Lic. Plate # U21)___2-e-lC <br />e I <br />3 <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 permi older must notify the EHD. Failure to notify this office may result in permit <br />revocation a penalties. <br />OMMISSARY OWNER/OPERATOR <br />412-11z,21eil • / ) <br /> <br />d _,/ FA# <br />2 . Bus. Phone_Z_ZZ:__Y_Oi__:_kC_-- <br />/ ,gr <br />Zip 5___—_Owner sperator <br />Check all appropriate services provided: <br />in Wastewater disposal Di 3-compartment sink <br />r-CA <br />, 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 noti the EHD immediately. <br />Signature. <br />.be corn leted b the ENV HEALTH urisdiction outside of San Joa uinto! <br />Business Mailing Address <br />City --1-“,,,ttA State C-tt Zip cl537(p Bus. Ph. <br />I, Cl R CA_ VV't- <br />Date c 2o2 <br />Signature <br />,Z To be 'borril-e-ted b <br />DI Solid waste disposal <br />a Hot & Cold water for cleaning <br />0 Store dry food/supplies <br />Food preparation <br />0 Store refrigerated food <br />B Overnight parking <br />Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />Vehicle wash <br />Date <br />The commissary is located in <br />County. The above food facility meets the _ <br />commissary requirements in <br />California Health 8i 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 />Date <br />REHS Signature <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sIgov.orgiehd