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�'°`"-c SANsIOAQUIN Environmental Health Department <br /> L1I' 4' COUNT Y— <br /> �,�i Greotness qre,-.s here. <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 /> Business Name f S 6 ic.Plate# V a <br /> Owner/Operator Name 2 r l_ OZC - <br /> Business Mailin Address 3 E_ Y <br /> CdY State Zip L1 �SBus. Ph. �70_ht. PI . <br /> I, 1cyl I <br /> C_Qhereby state that the above information is currtent,true and correct to <br /> the best f 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 enalties <br /> Signature <br /> GY_44V� Oros <br /> Date ri— <br /> Commissary Nameo-nMM4, ( G FA# <br /> Address1az 0 �,C(,f('cC'x�2 A+Q S 4-- Bus. Phone Z - 33 <br /> City Zip qS 2y� Owner/Operator <br /> �G <br /> Check all appropriate services provided: <br /> Wastewater disposal g 3-compartment sink Xt Electri I hook-ups <br /> 6,, "Solid waste disposal T od preparation V Toilet nd handwashing <br /> 1�-t-tot & Cold water for cleaning Store refrigerated food 1:!�Potabl�e water <br /> Store dry food/supplies `y Overnight parking -MVehicle wash <br /> I, M , hereby state that the information I have provi;ed is current,true and <br /> correct to the best of r9y 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 m ified or cancelled, the <br /> commissary owner shall notify th HD immediately. <br /> ZZTheSignature Date 2 Z 7X02- <br /> The <br /> commissary is located in County. The above Mood 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 I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.orc3/ehd <br /> OLGsY-4920 <br />