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SAN MAMA <br />—COUNT.Y - <br />6,eutile“ arms <br />Environmental Health Department <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 3. <br />1. To be completed by APPLICANT <br />Business Name /2 Lic. Plate # 1/ezio <br />Business Mai ing Address 3 317 4/ <br />City Iti2L Statee# Zip (D Thus. PhACI• 90)- 6137 Alt. Phkg--;(---- <br />1,11 del Cie 1\iti gz2 , 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 />SignatureX <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Nam t.,(2 <br />Address y9 1) e .ez.634,41 /41 b6) <br />City Zip 7c() Owner/Oerator <br />Check all appropriate services provided: <br />siK, Wastewater disposal <br /> <br />`K 3-compartment sink <br />Solid waste disposal <br /> <br />Food preparation <br />X Hot & Cold water for cleaning „_ Store refrigerated food <br />ore)dry food plies 7)( Overnight parking <br />I, 0/r/Ve A47 4/4447:___ , hereby state that the information <br />nd meets the California Health & Safety Code requirements. If the food facility <br />nditions of this agreement, or if this agreement is modified or cancelled, the <br />HD immediately. <br />Date <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <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 Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />Owner/Operator Name t-4)7) a Li' <br />Date / — — <br />FA# <br />Bus. Phoned 19g Z/ <br />X. Electrical hook-ups <br />X Toilet and handwashing <br />Potable water <br />Vehicle wash <br />I have provided is current, true and <br />correct to to the best of my knowledge, <br />operator fails comply with the <br />commissa owns shall notify t <br />Signature