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w . SQ �9�OAQUIEnvironmental Health Department <br /> '" —COUNTY— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility a Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> Business Name L A- -1 fN V 9 i Lic. P ate# ' W J <br /> Owner/Operator Name —n <br /> Busines Mail' ddress <br /> City L tate� � <br /> ZA Q Bus. Ph'LO '0 1 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 penalties. <br /> Signature I vii a Nc'sn fie. avb4icnc Date 7i <br /> CommissaryNam �1 � <br /> Ad re s -I c7 V S - Bus. Phone <br /> Ci tyS Zip �S2 Owner/Operator ✓ n� <br /> Check all appropriate services provided: <br /> EfVWastewater disposal compartment sink WEIectdcal hook-ups <br /> Er' <br /> SSolid waste disposal 13-food preparation filet and handwashing <br /> C of& Cold water for cleaning Store refrigerated food �ri ble water <br /> tore dry food/supplies Overnight parking Cdf Vehicle wash <br /> 1, , 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 t my <br /> with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary o er II no ply <br /> the D immediately. <br /> Signature tcvtit.(�� Dat �� <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 EHD if the status of their operating permit changes. <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton. California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />