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SAN jOAQUIN <br />I <br />nvironmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility * Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />4 To be completed by APPLICANT <br />Business Name Zl C'(nc�fyc6-) Lic.Plate# 6 - ?-oVZ <br />commissary is discontinuef , the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and oenaltieY <br />12- To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 47fz!1!:.. FA# <br />Address ZP20 _S S'li.� sl— Bus. Phone (Za9) zLN- 8359 <br />City L-OL2 r' Zip `l5Z,* Owner/Operator A(W Iia' rw 622 -- <br />Check all appropriate services provided: <br />1liastewater disposal compartment sink <br />olid waste disposal <br />J�'�Hs�-ot & Cold water for cleaning <br />I/Store dry food/supplies <br />®Food preparation <br />Core refrigerated food <br />3-�O'vernight parking <br />Lk6ectrical hook-ups <br />Diet and handwashing <br />(potable water <br />Chicle wash <br />I, , 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 shall notify the EHD immediately. <br />Signature �/`�� Date 7 ` 7Z <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 Stockton. California 95205, T 209 468-3420 F 209 464-0138 1 www.s,,gov.org/end <br />Y <br />