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SAN <br />JOAQUIN Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Complete sections 1 and 2. <br />Business Nan-- <br />Owner/Operator <br />if your commissary is located outside of San Joaquin County also complete section 3. <br />Plate# orl 9- S5 <br />Business Mailing Address6l 'd '/,7- i'' W aln rr az <br />city �1) t „„ State zip aSj2f CBus. Ph. -:S -3I — q`LS I Alt. Ph. �cio — �� <br />1, 0,4 t 6` 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. 1-2-3 <br />nate 14111 <br />2. To be completed by COMMISSARY UtNNt' "' "-- "'''r. <br />Commissary Name FA# %DSf 3Lc1-l i � <br />Address 1 Z�O 1 5 �ccr- 5 - Bus. Phone ?u3cl - ZS% 3 <br />City � -oCa 1 Zip �I Owner/Operator 1 I t a _� ry e 7 <br />Check all appropriate services provided: <br />O 3 -compartment sink Electrical hook-ups <br />Wastewater disposal P <br />preparation Solid waste disposal <br />❑ Food pr.Toilet and handwashing <br />Hot &Cold water for cleaning ❑ Store refrigerated food ❑ Potable water <br />,AdOverni ht parking }Vehicle wash <br />❑ Store dry food/supplies � g P g // <br />hereby state that the information 1 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 />e con 'ions of this agreement, or if this agreement is modified or cancelled, the <br />operator fails to gomply with th <br />commissary oyd*r shall notifyVlhe EHD im tely. r. _ t t — ^` <br />3 To be completed by the ENV HEALTH jurisdiction outside of San Joa din Co. <br />The commissary is located inCounty. The above food faculty 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 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 i www.sigov.orglehd <br />