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commissary o sh notify the ElDjmediately. <br />—1%464- Date/O- / —e Signatu <br />SANAOAQUiN <br />COUNTY-- <br />Greatness grows 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 />1.)10 be completed by APPLICANT <br />Business Name T) //'fl S 2Lic.Plate # '577 <br />Owner/Operator Name Ar-/ C I C• A Corerr et0 far <br />Business Mailing Address — E0 ;ii S <br />City s StateCk Zip 75-0..Si3us. Ph.20?.116. .2_ Pt 2 S-Alt. Ph. `2c) 7. o7 V ? <br />/-\\C_ 'C ue),2A-o , 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 ust notify the EHD. Failure to notify this office may result in permit <br />revocation and pen 9s <br />Signature Date — <br /> <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 'E\ (n.x—v FA#, <br />Bus. Phok) 09) l Tk2S <br />cityStDC54-4-0-n Zip CA- Owner/Operator Altc ck. <br />Check all appropriate services provided: <br />Address 1_251 rr)attr\ <br />•astewater disposal _ <br /> )Solid waste disposal <br />Hot & Cold water for cleaning <br />IX Store dry food/supplies <br />et 3-compartment sink <br />ga Food preparation <br />IF Store refrigerated food <br />In Overnight parking <br />MI Electrical hook-ups <br />IR Toilet and handwashing <br />Potable water <br />0 Vehicle wash <br />1, cvt.CA 3R---V—v"42-."(-) , 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 />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in 500'.\ _S Da/ County. The above food facility meets the <br />commissary requirements in California Health & S fety 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 I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd