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' <br /> ' � �U � � �U �0 Environmental Health;[ ��n�vn ����n�~�~° oov -- ~ <br /> --COUNTY— <br /> (�veutness <br /> ' <br /> COMMISSARY AGREEMENT <br /> MOb'|8 FOOH F8Ci|itVt, Caterer <br /> Complete Ifyour commissary is located outside ofSan Joaquin County also completesection 3. <br /> NT <br /> bV <br /> Business Name ?) 12- Lic. Plate# L9 5--s P <br /> Business Mailing Address <br /> City to i Bus. Ph. Alt. Ph. <br /> | hereby state that the above information iscurrent,true and correct ho <br /> the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Codo. and San Joaquin County Environmental Health Department (EHO) requirements. If the use of the <br /> commissary iodiscontinued, the permit holder must notify the EHO. Failure tonotify this office may result inpermit <br /> revocation and penalties. <br /> / '7 <br /> 5ignxdu at <br /> Address Z,�)O_g Bus. Phone <br /> City zip Owne erato <br /> Check all appropriate services provided: <br /> 0 Wastewater disposal It 3-compartment sink 0 Electrical hook-ups <br /> it Solid waste disposal Ell Food preparation 0 Toilet and hBndvvaShin0 <br /> Hot & Cold water for cleaning 13 Store refrigerated food ^ Potable vv@te[ <br /> 0 Store dryfood/sUpp|ie8 IS Overnight parking 13 Vehicle vV88h <br /> |, hereby state that the information | have provided is currant,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 agnaement, or if this agreement is modified or oonce||md, the <br /> commissary the EHD immediately. <br /> � <br /> Signature Date <br /> th <br /> e ENV HEALTH jurisdiction outside of San Joaquin,'Co.' <br /> The commissary islocated in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checked services one available at the <br /> above commissary. Please notify EHD if the status uftheir operating permit changes. <br /> REHS Signature Date <br /> 1888E. Hazelton Avenue I Stockton, California S52051 T 2O8408'3420 | F 20S464-0138 | vmxxw.cjguv.org/ehd <br />