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�AN - JOANN Heaikh U- spaFtment <br /> COMMOSSARY AGREEMENT <br /> Mobile Food Facility ,- Caterer <br /> Complete sections I and 2, if your commissary is located outside of San Joaquin-County also complete section 3. <br /> Business Name i Lic. Plate# - - / <br /> Owner/Operator Name G cAvesA A i- rer - <br /> Business Mailing Addressl ��,t'c �« `— <br /> City Stat -ZipCBus. Ph, Alt. Ph. <br /> [, 1 hereby state that the above information is current,true and correct to <br /> the gest of my knowledge and gr utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San J ui o E ironmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontin e e e old r must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penaltie <br /> Signature Date 0 <br /> OU �OPERATOR <br /> Commissary Name_ f 1_�f K C !:�C' CRE O Cn, FA# <br /> Address 3n�!�/ Bus. P <br /> hone_ <br /> City rlOT6 Zip � o Ow perator <br /> Check all appropriate services provided: Zrt. <br /> ..r�� <br /> Om <br /> Ham' <br /> M Wastewater disposal 0 3-compartment sink Electrical hook-ups prs <br /> E3 Solid waste disposal 0 Food preparation U"�Tdiiet and handwashing 0":;g C <br /> Z m <br /> E3 Hot& Cold water for cleaning U—More refrigerated food 0 Potable water Z C. <br /> 13 Store dry food/supplies overnight parking U Vehicle wash <br /> I, , hereby state that the information I have provided is current,true and em <br /> correct to the best of my knowledge, and meets the Califomia Health&Safety Code requirements. If the food facility M <br /> operator fails to comply with the conditions of this agreement, or ff this agreement is modified or cancelled, the r,�a <br /> commissary owner shall notify the EHD immediately. <br /> Signature r C - Date <br /> kk- be corn by the ENV HEALTH jurisdiction outside of San Joa uin Co. <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in Califomia 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. <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, Califomia 96205 i T 209.468-3420 I or 209 464-0138 i www.sjgov.org/ehd <br />