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ZZ ff :07 <br /> SAN-A-0A IN Environmental Health Department <br /> tz �; —COUNTY— <br /> �' Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility i Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> Business Name \� I , /��� 1 / f, Lic. Plate# �f1s r <br /> Owner/Operator Name 1�� �rr� T�� ft5 • U IL–cf_ � <br /> Busin ss Maili/In Address l b� C UM l <br /> Cit l State Zip2 kL_ Bus. P Alt. Ph. <br /> I, 17 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 enaIties. <br /> Signature Date �'V <br /> Commissary Nam 11�A n FA# <br /> c <br /> Addr I b>/' (�1s Bus. Phone <br /> City Zip " IJ� Owner/Operator ) �� A l�} <br /> vim---� <br /> Che all appropriate services provided: � <br /> Wastewater disposal f�ompartment sink II�lectrical hook-ups <br /> Zid waste disposal ood preparation oilet and handwashing <br /> t & Cold water for cleaning 0 Store refrigerated food otable water <br /> tore dry food/sup <br /> �p/��es 9.efvernight parkingicle wash <br /> res <br /> / 41/OV _ hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,andYneets 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 /> commissa owne shall n tify the D immediately rte <br /> Signature Date v <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, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />