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SANsJOAQUIN Environmental Health Department <br /> —COUNTY <br /> G <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections I and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 70 <br /> Business Name ORV_4- Lic. Plate# <br /> Owner/Operator Name_%40-x_-r-t C_Lj.'2 <br /> Business Mailing Address 3 7-c <br /> City ZiP_L:,;-i Bus. Ph.n, Ph. OV JK", 9 <br /> 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 penaltieq. <br /> 7. <br /> Signature Date <br /> Q 0,N'.M, <br /> Commissary Name Pc;�(I r 0 FA# <br /> - *�' 4 <br /> Address k"'if 2"A-4 4. ; Bus. Phone <br /> IP <br /> City-ST-D Z Owner/Operator <br /> Check all appropriate services provided: <br /> )2 ,Wastewater disposal [3 3-compartment sink V(Electrical hook-ups <br /> 6f-Solid waste disposal [3 Food preparation °„Toilet and handwashing <br /> [3 Hot&Cold water for cleaning El Store refrigerated foodIKPotable water <br /> I— - <br /> [3 Store dry food/supplies 7$overnight parking 13 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 /> 0 P <br /> operator fails t �gm p4-w thitions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary own h i the E44D immediately. <br /> Signature <br /> Date 7_6 <br /> K. <br /> 13., 1.1 1 - hILK.,WINAW <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 /> I I <br />