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SAN iOAUlN <br /> <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Complete sections 1 and 2. If your commissaty is located outside of San Joaquin County also complete section 3. <br />City <br />1. To be completed by APPLICANT <br />Lic. Plate # L <br />570 -77( 510/Alt. Ph. <br />I.1T1 ft , 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. <br />Signature Date 7774// <br /> <br />Business Name p1t,44 le ) S woky Cfec..en <br />Owner/Operator Name Acjr,L, Trc-t6 <br />Business Mailing Address r1-i-,0 c+ <br />City 51'octc c/7 State c,4- Zip /C.1-0‘. Bus. Ph <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name gr -tai-oiti FA# <br />Address E 1-06-YE" 11-11E: Bus. Phone c73 /S-11( <br /> <br />5 7"k_12) A) Zip 'pc/ 0 C Owner/Operator Lleeilce wed-- <br />Check all appropriate services provided: <br />o Wastewater disposal <br /> <br />3-compartment sink <br />-Solid waste disposal <br /> <br />0 Food preparation <br />El Hot & Cold water for cleaning C.YStore refrigerated food <br />0--8-tore dry food/supplies Cenvernight parking <br />I. E'N C14-4-0 <br />a<cetrical hook-ups <br />1&let and handwashing <br />la-Potable water <br />0 Vehicle wash <br />, hereby state that the information I 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 conditionao this agreement, or if this agreement is modified or cancelled, the <br />commissary o ner shall notify the E lately. <br />20 )9 <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <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 />RENS Signature Date <br />1868 E. i-lazeiton Avenue I Stockton, California 95205 I T 209 468-3420 F 209 464-0138 I www.s..igov.orglehd <br />Signature <br />Date