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v <br /> S & & O & Q U U N Environmental Deppirtment <br /> ' <br /> COU <br /> ^ ' <br /> �TY--- <br /> COMMISS ~ nAGREEMENT <br /> Mobile Food Facility o caterer ' <br /> Complete sections fand 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> Owner/Operator Name -1-A..5---ra ff I tZ 15 j:jQ <br /> Business Mailing Address A62-til ir. . jj4"j <br /> 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 /> revocationand penalties. <br /> SignatureX_��,-�IC- �P_�6 ...Date <br /> A. <br /> Commissary Name Q 016 7-6a FA# <br /> Address 1 (010 VA n) Bus. Phone 20 V 2-- <br /> city zip q <br /> Check all appropriate services provided: <br /> Q(Wastewater disposal 13 3-compartment sink M E.e^".^a. .."""-"p" <br /> =��� <br /> E�y Solid vvaotedisposal [3Food preparation mm /oi|etondhandxvonhing <br /> P( <br /> �� Hot�� ��o|dvvoherforc|eaning 0 Store mfrQenatedfood �� Pobab|ewater <br /> mm�� <br /> [3 Store dryfood/mupp|ies M���nern' ht parking m* "ehide wash <br /> ____. hereby state that the information |have provided iacurrent,true and <br /> correct to the best of my knowledgefand meets the California Health&Safety Code requirements. |fthe food facility <br /> operator fails to comply with the conditions of this a0neomnent, or if this agreement is modified or oonne||ed. the <br /> commissary own all nre EHD immediately. <br /> Signatur ----Date <br /> The commissary in 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 EHDifthe status oftheir operating permit changes. <br /> REHSSiQnetuDate <br /> '- <br /> 1OO8E. Hazelton Avenue I Stockton, California 852O51 T 2U9408-34201 F 208464-0139 ]vwvw.sjgov.o,g/uhd <br /> :-MAK � �� ��� <br /> ' � v� .��� u� ' <br /> ° �Cs�s <br />