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SAN IOAQUIN Environmental Health Department <br />—COUNTY— <br />COMMISSARY AGREEMENT <br />Mobile Food Facility 4 Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Business <br />Owner/Operator <br />I lii% t -E c p- A rl <br />tJ <br />Plate # �R %ii , <br />Business Mailing Address wLl Z-t/3X3X-�� 1 <br />City// �C GCTU StateChZip 2 C i � Bus. Ph. �- � s `73o%Alt. Ph. <br />I. J 1 ����1` `� `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 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 penalties. / p <br />Signature lad�`7 ') (nv. ��'..;ni Date it—' 2- -262.1 <br />12. To be completed by COMMISSARY OWNER/OPERATOR <br />IGjG f DloCk / c G L F <br />Cgmmissary Name lY Lui %��'�" �- <br />Address l �(3 0 - wC6E lZ /-� UE:-�:: Bus. Phone <br />City STUc1`7b"'� Zip �S 20� <br />Check all appropriate services provided: <br />El -Wastewater disposal <br />® Solid waste disposal <br />tct S -compartment sink <br />F3 Food preparation <br />123—Electrical hook-ups <br />i -Toilet and handwashing <br />Q Hot & Cold water for cleaning €Store refrigerated food 13'1otable water <br />St, e dry food/supplies 0 -Overnight parking 13 Vehicle wash <br />I, `y% -.L i Q 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 comply with the conditions of this agreement, or if this agreement. is modified or cancelled, the <br />commissary owner A{shatl otifythe�E -LI <br />'�yf-{( <br />Cinnnhiro IC:/`�— - "�"V(i �V et Ni 'f7RYP I 1 / I <br />HEALTH <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 <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 />