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SAN 10AQUIN Environmental Health Department <br /> C O U N T Y------ <br /> COMMISSARY AGREEMENT 1, <br /> Mobile Food Facility • Caterer <br /> Complete sections 7 and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br /> Business Name Allt _anLic. Plate# <br /> Owner/Operator Name AA"ro Wa,'V5O n <br /> Business Mailing Address 1 510 ke opr+ A\)-e <br /> City & State(A Zip °l , 2D 5 Bus. Ph.I�N-110 -119 & Alt_ Ph. <br /> I, A Ol 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. J <br /> Signatu Date_ <br /> Commissary Name_zzl�-e'a' L/' FA# <br /> Address 's?"ZVZW'1'�-e— 4- Bus. Phone (-z�) a.2y --F3 5y <br /> City L-ip� ' Zip SZ10 Owner/Operator y �Gs <br /> Check all appropriate services provided: <br /> M-4astewater disposal compartment sink lectrical hook-ups <br /> U5olid waste disposal �� ood preparation __� oiiet and handwashing <br /> �ot & Cold water for cleaning 'Storem� refrigerated food 0"P��otable water <br /> Store dry food/supplies 0,16vernight parking 11,1-ehicle wash <br /> I, iZ� , 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 /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall notify the EHD immediately. t <br /> Signature �� -- Date <br /> [3. To be completed by the ENV_HEA_L:TH jurisdiction outside of San Joaquin C70 ' <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 I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />