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I <br />SAN JOAQUIN <br />COUNTY — <br />Greatness arcws here <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 />To be completed by APPLICANT <br /> <br />Business Name () 5 i9 <br /> <br />Lic. Plate # ?:-:-3.41 <br /> <br />Owner/Operator Name <br />Business Mailing Address q71/,p C 't(U- , <br />/ <br />_417-7) 01- 9c-J_1c <br />1 ,,,,,, -, . Statterk Zip_26,16___-• — Bus. Ph. 9t_oi--7,/,--4-fe) --4S--Alt. Ph. <br />I i 174 Alt 14441:6 e id , 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 peli-61t1 <br />Signature <br /> <br />To be completed by COMMISSARY OWNER/OPERATOR <br />/ <br />Date <br />Commissary Name <br />Address3Kili e <br />Cityig-he' <br />PlAtta.t.-A1 Ci.1)L-Gd <br />(thilthc <br />Zip CN)citi Owner/Operator <br />FA# <br />4,0,041,f:/ arkfitti-P <br />Bus. Phone <br />Check all appropriate services provided: <br />Wastewater disposal N.t. 3-compartment sink <br />. Solid waste disposal Food preparation <br />Hot & Cold water for cleaning Store refrigerated food <br />re dry food pplies <br />„( <br />OW /7 , hereby state that the information I have provided is current, true and <br />correct to the best of my knowledg and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to. comply with th onditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary 4r shall notie .EHD imme <br />Signature .0-r-r-ett Date, 7,1- j <br />Overnight parking <br />Electrical hook-ups <br />N4s. Toilet and handwashing <br />Potable water <br />Vehicle wash <br />3. To be completed by the EN LTH 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 />REHS Signature Date <br />1868 E. Hazelton Avenue Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 worw.sjgov.org/elid