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SAN J OAQ U I N Environmental Health Department <br /> -v - <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 /> -7 <br /> Business Name � ( ��� �� / I f l��—�� !05 ci/11Cic. Plate# <br /> Owner/Operator Namemc <br /> b �� <br /> Business Mailing Address e Gly TAf)6,Y1CAL 1,vAy <br /> City/4 0�9.ilQ StateLL+ZipC�,sJ�1 H Bus. Alt. Ph. <br /> 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. <br /> Signature Date <br /> WIMMI-11-0-1-M "R- 104160 <br /> Commissary Nameecxmrf\.�`L- (')_'\ FA# <br /> Address(4/4) �.� 7 4 Bus. Phon rte' 22 --6 `31 1 <br /> City LCA-" Zip '-kC Owner/Operato x3c) 1 <br /> Check all appropriate services provided: <br /> 16 Wastewater disposal * 3-compartment sink '(Electrical hook-ups <br /> Solid waste disposal ood preparation Toilet and handwashing <br /> rM Hot & Cold water for cleaning ;U Store refrigerated food Potable water <br /> A Store dry food/supplies Overnight parking ,l<Uehicle wash <br /> Lf� yy&� m hereby state that the information I have provided is current, true and <br /> correct to the be0of 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 o ner sha tify the EHD immediately. <br /> Signature Date <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. Hazeltor, Avenue j Stockton, California 95205 1 T 209 468-3420 i F 209 464-0138 ! www.sigov.org/ehd <br />