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SA N d 0AQ U IN Environmental Health Department <br /> COUNTY---- <br /> . <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer - <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. Tobe:com " Ieted:'b YA �f � �� 9 ���.n{V; r, v � ; Y . <br /> i, h .! Lti aei a yW, F +ij <br /> Business Name a.+ 1 S efvim' '+ ,Fab Lic. Plate# 5$J 701 a c2 <br /> Owner/Operator Name �Tjt JwS &Zg5"R A� <br /> Business Mailing Address <br /> City L44t' StateC.,!,,.Zip us. Ph, z4• 4-v*-.t"'- rr� <br /> l 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 /> SignaturC 6G DateAzrj;�l <br /> Z <br /> T __;•, {{•�,�' i rSiI.. Y � v{zhli <br /> 2. To ibex 00171 eUAsi +A� f t a. W'LIfr1AV a �ik � <br /> Commissary Name_L 14 pj 7 FA# a09`� <br /> Address , (p 2=0k- ��r 1'-1 ►� �. _ Bus. Phone Og - <br /> City Lwi4 hcr-,o _Zip Owner/Operator t-��Vx— <br /> Check all appropriate services provided: <br /> Wastewater disposal ❑ 3-compartment sink Electrical hook-ups <br /> Solid waste disposal ❑ Food preparation q2 Toilet and handwashing <br /> ® Hot & Cold water for cleaning ❑ Store refrigerated food [� Potable water <br /> ® Store dry food/supplies a,/Overnight parking L Vehicle wash <br /> 1, , 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 own hall no ' e EHD immediately. <br /> Signature Date -7/ ;—P <br /> ..�. .y. y., yt.;e. <br /> 3. To "b corn letedb gat# ri`� tsl �oS` tCa <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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />