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,��pUSX <br /> ; } SANAMUIN Environmental Health Department <br /> COUNTY— <br /> �`4t"ti i Greatness grows Iere. <br /> _. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections f and 2. ff your commissary is located outside of San Joaquin County also complete section 3. <br /> Business Name Non i? �1 m ft^ ' x Irp1N ��ic. Plate# lLI , <br /> Owner/Operator Name * L�� <br /> Business Maii'ng Address fi- 1 <br /> City Stat Zip S Bus. Ph'W� as2�It. 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 Co ty Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, the unit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date 2 <br /> Commissary Nam ` J /) <br /> Addre s ' Bus. Phone ZCiV6.6 Zip-15///fJ//�!)TOwner/Operator <br /> Check all appropriate services provided: <br /> (r'W1 astewater disposal 0-1-compartment sink VSectrical hook-ups <br /> Ar-5olid waste disposal P-f—ood preparation oilet and handwashing <br /> of old water for cleaning 9'-&ore refrigerated food RIPotable water <br /> Staria d food suppli s vernight parking ehicle wash <br /> I, _Y�44 g?d hereby state that the information I have provided is current,true and <br /> correct to the best of my nowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to com ly with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissa o r alf n th HD immediately. <br /> Signaturery /z t.ZZa4Date_] !� <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in Calif is Health & Safety Code. The above checked services are available at the <br /> above commissary. Please no' EHD if the status of their operating permit changes. <br /> REHS Signature Date <br /> 1868 E. Hazelton Av ue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />