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SAN JOAQUIN Environmental Heaith Department <br /> <br /> <br />if this agreement is modified,or cancelled, the <br /> / 7.~ / Date <br />Date <br />The commissary is located in <br />commissary requirements in California Health & Safety Code. <br />__FA#_________ ____ <br />yr ** s . <br /> ron oatgi^of San Joaquin Co <br />County. The above food faciijj<meets the <br />■ -------------. i he above checked services are available at theabove commissary. . lease notify EHD if the status of their operating permit changes. <br />REHS Signature <br />w.v.sgcv.crc e-c <br />CDC)^ <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Comp/ere sect/ons 7 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Lie. Plate # 5^6 $ S,S£) Business Name .rl Jg /q <br />Owner/Operator Name \!^)^ ____ <br />Business Mailing Address S , <br /> Cl^~^ ci?--------state^_zip^sz4fiBus. Ph.fzy ^6 3/I Ay Ait Ph.2^y <br />thehH^n-' h--------77--------------’ hereby state That the above information is current, true and correct to <br />Safet^ H °Wled?e and agree t0 utllize my aPProved commissary in accordance with California Health & <br />commi^n anQ qUun niy Environmental health Department (EHD) requirements. If the use of the <br />commissary .s discontmuec. the permit holder must notify the EHD. Failure to notify this office may result in permit <br />invocation and ni_ -r» <br />;______Date /Z//^ <br />'8SS Hazeiic- Avenue S:cckton. California 95225 T 2C9 435-3422 F 209 464-2'38 <br />Commissary Name ____/i <br />Address,^Jph Blls Phone <br />C'ty-------TzLffi1"--------------Zip Owner/Operator <br />Check all appropriate services provided: x <br />E^stewater disposal ^^npartment sink CS^tertrica! hook-ups <br />^Sohd waste disposal CZ^0Od pfeParation and handwashing <br />ooio water tor cleaning ,^/ Store refrigerated food jZ^ojaele water <br />2H>iore dry rood/suppiies ^Overnight parking ^Vehicle wash <br /> t - hereby state that the information I have provided is current true and <br />correct to the best ot my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator rails to comply with the conditions of this agreement, or----- <br />commissary owner shall notify the EHD immediately. <br />Sign at u re_____