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kr re 0 6 <br />SAN JOAQUIN <br />--COUNTY-- <br />q- t ws <br />Environmental Health Department <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 />1. To be completed by APPLICANT <br />Business Name ri-005 t L IIFiE <br /> <br />Lic. Plate# 7039/3, <br /> <br />Owner/Operator Name C ii-grxeL 6 GM 7-"/ <br />Business Mailing Address 3 qll MORI ) <br /> <br />, 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 pe lties. (...„_n3 <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name IA100 f‘l C neuck. CenfrEA FA# <br />Address / 7 1 7 . ON( 04 T <br />City .57-0T,M7, Cl/ Zip &ZOC <br />Check all appropriate services provided: <br />mvWastewater disposal <br />re/Solid waste disposal <br />4lot & Cold water for cleaning <br />Wgtore dry food/supplies <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 conditions of this agreement, or if this agreement is modified or cancelled, the <br />all notify th HD im ediately. <br />Date <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 <br />Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />City Tic k..To NJ State e.-ItZip zoc Bus. phaz3? 7-78- 93 Alt. Ph. <br />C/9141 /2 Ô 6' Apr-ii <br />Signature ct< Date /44 4-0 2-0 <br />Bus. Phone 2. <br />I, <br /> J9 f()( "ri,4 L) <br />af'3-compartment sink <br /> <br />flilectrical hook-ups <br />CYFood preparation <br />raVToilet and handwashing <br />a'tore refrigerated food <br /> <br />ra"Potable water <br />E"Overnight parking <br />i3/ehicle wash <br />commissary owner <br />Signature