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SAN.,)OQQUfN Environmental Health Department <br />I --COUNTY— <br />;.>' Greatness grorrs here. <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 />1..To be com feted by APPLICANT <br />Business Name'0P&rlaEf2-5 501o9C 77yvzoPG11 13.13•Q. Lic.Plate# <br />Owner/Operator Name 'IAMl1N L ID. Sy.ul,C y <br />Business Mailing Address I t 1N CA1zLTvN i4✓C <br />City 51b(kTvN Staten/4 Zip 2 !5-2&s Bus. Ph.��� Zoz3' !;)V` Alt. Ph. <br />I, aAmAnd. D. 50'V L4 y . , 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 />atCheck II appropriate services provided: <br />ewater disposal 3 -compartment sink E3 Electrical hook-ups <br />/ol' waste disposal C d -preparation Toilet and handwashing <br />y� Hgt�6�Cold water for cleaning / Store refrigerated food Potable water <br />aSt� plies fa Overnight parking 0 Vehicle wash <br />I. yC' , 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 to co/i�p with the condilio s of this agreement, or if this agreement is modifield,([o�yj)�aJncelled, the <br />commissary owner'sh II tifytheEH ediately. 5(1"T v f <br />I i <br />3."To'be completed.by the ENV HEALTH jurisdiction outside ofSan 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 I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />