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et e- ENV H 1 isdiction outside of San Joaquin <br />owledge, and meets the California Health & Safety Code requirements. If the food facility <br />y with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />r shall notify t HD immediately. <br />Signature <br />correct to the best of my <br />operator fails to co <br />commissary ow <br />2c.) Date /~i)i— <br />stewater disposal <br />d waste disposal <br />Hot & Cold water for cleaning <br />0 Sre dry food L.ipplies <br />I, <br />SAN•JOAQUIN <br /> <br />Environmental Health Department <br />CIJN 1':( • <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 <br />Owner/Operator Name (11.-i(tho <br />Business Mailing Address 473‘ csAke <br />City 7; (So rv‘_ State(A. Zip onIfo Bus. Ph. ?/6 /TOP/V-7 Alt. Ph. <br />Pat\ I ('7e13ird , 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 pe mit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and • - • _ - s WAIF <br />Signatu •4 &A, Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name VFW FAST 6.6611 FA# <br />Address t OO f T Bus. Phone q <br />City Zip3S-62YO Owner/Operator cret 47/-06-11' <br />Check all appropriate services provid,edy <br />compartment sink 0 Ectrical hook-ups <br />t'Food preparation ó-'øtiet and handwashing <br />0 Store refrigerated food Potable water <br />0 Overnight parking 0 Vehicle wash <br /> hereby state that the information I have provided is current, true and <br />The commissary is located in .50-C Ca vvl-cv-I-tt) 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 E D if he status of their opKating permit changes. <br /> Date -213 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/end <br />PRUSL1 IP <br />/4/Alre fitAfet/ Lic. Plate # <br />REHS Signature