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SAN JOAQUIN Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ;, caterer <br /> complete sections I and 2 if your commissary is.IocaWs outside of San joeiluit, county also Complete section 3. <br /> LIE- <br /> BusinessNamJN) P-) c\ I 4n h I(L )Llc. Plate# <br /> Owner/Operator Name M <br /> Ph. <br /> I, _,heraoy stale that the atxive information is current,true and correct to <br /> the bast of my knowledge anti agree to utilize my approved cammissaN rn aoaordance with California Health & <br /> Safety Code, and Sa 'Joaquin County Envuonmentaf Health Department (ENCS) Ms. If the use of the <br /> commissary is inued, he permit holder muss of fy the END- Failure to notify this office may result in permit <br /> revocation an pe sties. <br /> Signature <br /> Y___Vk#�ERATOR <br /> 0 <br /> Commissary Nam Vl1' nh <br /> Address phone <br /> City <br /> Ch k all appropriate services Provided: <br /> wastewater disposal D__3�comipartrnent sink C?'fliactri.cal hook-ups <br /> es�olid waste disposal 121�00d preparation 3�_Toilet and handwashinq <br /> 914ot& Cold water for cleaning 0 St a refrigerated food V'Potable water <br /> M-s-'tore dry food/supplies �Zvernfght' parking u_4­ehicle 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 /> operator fails to rr <br /> _ ly with the conditions of this agreement or if IN agreement is modified or cancelled, the <br /> cog pd <br /> ary ow S=0tify <br /> Si nature <br /> Q/ Data <br /> The commissary is located in --County. The above food facility meals the <br /> commissary requirements in California Health & Safety Code, The above checked servio.s are avallebia at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> RENS Signature , Date _....._,. <br /> 1868 E. Hazefton Avenue i Stockton, California 95205 1 T 209 468-34201 F 209 464-0,138 1 woAN.sj9c,,orgiel-id <br />