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11,411, <br />:IL IF 09e- <br />SANIJOAQUIN <br />--COU NTY— <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. To be completed by APPLICANT <br />Lic. Plate # 7/ <br />0)-‘ 1'Q2 <br />Business Mailing Address gig I/ie7 Q9' (76-a ity9e;) (' c.) <br />City cony State ca-zip 752o Bus. Ph.2-0g- 27.--0,5Alt. Ph. <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 penalties. <br />Signature Date <br /> <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 9z-t.--6/-c, Loomio-yx- FA# <br />Address 6 Zd 5 vtizAt-tr, 54 '13 296 Bus. Phone 2- — 6 3 5 7 <br />City /...0 Zip 9 5z-co Owner/Operator It j re) 6Ta'/GL_ <br />Check all appropriate services provided: <br />I'Wastewater disposal CI 3-compartment sink erKctrical hook-ups <br />liSolid waste disposal 0 Food preparation Toilet and handwashing <br />Hot & Cold water for cleaning 127S--t-ore refrigerated food botable water <br />10/Store dry food/supplies /Overnight parking 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 conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall notify the EHD immediately. <br />Signature g"tedV <br /> <br />Date <br /> <br />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 />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.orgiehd <br />Owner/Operator Name <br />1, <br />Business Name