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� � � �� � UY �� <br /> ����� v���KU� � y� ��n��~ron��entaX ��ealth ��e��an������ <br /> ' --�0UNTY-- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility # Caterer <br /> Complete sections 1and 2 Ifyour commissary is located outside ofSan Joaquin County also complete section 3. <br /> Business Name L L E. <br /> Business Mailing Address 3p,_3�2, W 141 P .10je <br /> (fa)l 05 he'reby state that the above information is current, true and correct to <br /> the best of my know-l—edge 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 /> Signature_'. LG S, Date <br /> COMMISSARY OWNER/OPERATOR <br /> Commissary Name <br /> AddressX3 _Z"11A S Bus. Phone __7 <br /> City Q� zip Owner/Operator <br /> Check all appropriate services provided: <br /> um ".as`"".m^e, u/spus*l a--3-compartment sink nfExe�nco/ hook-ups <br /> GII'SojWwaste disposal d preparation <br /> MT i dvvoshing <br /> 01 Mot & Cold water for cleaning 131"'Store refrigerated food drP o-w <br /> _ /' <br /> 21--store dry food/ lies ra ,Overnight parking MVehida wash <br /> |, heneUystate that the information | have provided iecurrent,true and <br /> correct tothe best nfmyknowledge, and meets the California Health &Safety Code requirements. |fthe food facility <br /> operator fails h | with h agreement is modified or cancelled, the <br /> commissary i: <br /> SignatureP <br /> Date <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 EHDifthe status oftheir operating permit changes. <br /> REHS Signature Ou1 <br /> 1868E Hazelton Avenue I Stockton, California 062051 T 209488'34201 F 209 464-0138 1wvww.sigov.org/phd <br />