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SAN JOAQUIN Environmental Health Department st. <br />C LI N I Y <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Complete sections 1 and 2. If your commissaiy is located outside of San Joaquin County also complete section 3. <br />1. To be completed by APPLICANT <br />Business Name \o.. Cob Lic. Plate #1-1511-,, (p32)11 <br />Owner/Operator Name (-5; )9Nro-i-tr, <br />Business Mailing Address \(:)15 p , <br />City StateGN Zip 457220 Bus. pOP"N-.2_16 --(kb Alt. PhttOe0`(- (17-5\ <br />r I, <4.),1,!i ,i`0, Ur' 0 c."Ar(.r---- , 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 dis itinued, the ermit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and Ales. <br />Signature Date C)()) \c0 2_oR <br /> <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissaiy Name So_c,j A/1 /1416617(< FA# <br />Address (96 Pri .97/6 ct_y Bus. Phone ,;? ex? 5 9 / 7.53 <br />City Arie.91C4re, Zip cr 53 5 / Owner/Operator C.) 4 <br />Check all appropriate services provided: <br />V.3-compartment sink <br /> <br />Electrical hook-ups <br />%Food preparation ..Toilet and handwashing <br />a Store refrigerated food <br /> <br />fakPotable water <br />rIL Overnight parking <br />P-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. lithe food facility <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissarrwrre shall notify the EH 1-n ediately. <br />To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in 13 /47,,, 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. Psejjtify EHD if the status of their operating permit changes. <br />REHS Signature Date - 207 <br /> <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgfehd <br />Wastewater disposal <br />Solid waste disposal <br />qk Hot & Cold water for cleaning <br />V/. Store dry food/supplies <br />el 0 )cr <br />Signature Date 6. —ci I cie <br />c. ve_ n oil-Qcti 4/ ,==f)c9c( c 75, otoe_s /.7 Cvnrkerl-Wy <br />hotRi c?' gQy to op Cr% •=1 -)- --f -7LA,..5 De yo 7/4., ee, p. %Well <br />5 -- /7 <br />tki o