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i 2 p`°UIN 'G t <br /> ° �c <br /> V A 1 �J O A Q U I {\ Environmental Health Def artment <br /> COUNTY <br /> Greatness grows here. <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 /> 1Qte.corhleted�b tow, [ NT ��r. sem. j�' .tom i <br /> Business Name C/9 R t< a S C -:;_ CAc--11 Lic. Plate# P k S/'I CA Q'T <br /> Owner/Operator Name Ca PL n S .6 L_ V'da Blr= �_ E—z4:5�44 F_-� } <br /> Business Mailing Address 5,5' <br /> City S is Stateq1 Zip Bus. Ph.D�-9-1,(d - 4 9;5'/ Alt. Ph. <br /> I, 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 /> .2 :To;;be come"leted-.b .'COMMISSARY,QMER%OPERATOR <br /> Commissary Name (� 1Cr m/ q e CR6:1 .t✓1 FA# <br /> Address 3 L4 I ���' nn Ll��r�G�y t-' Bus. Phone '-I9 pl- a"-r-- i yr <br /> City _5'7-n CK dn/ C- Zip Of Owner/Operator 570-'/j/)Q,, 7 C,fn/'Gi-Y <br /> Check all appropriate services provided: <br /> p Wastewater disposal E33-compartment sink -.\�>f� Electrical hook-ups <br /> p Solid waste disposal C0 Food preparation Toilet and handwashing <br /> © Hot & Cold water for cleanin\g\ �i Store refrigerated food C1 Potable water <br /> E3 Store dry food/supplies Overnight parking ® Vehicle wash <br /> I, , hereby state that the information I have provided is current,true and <br /> correct to the best of mKknowledge,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 /> Signaturei,, �.�:,,� .�'^ Date �: �"`a o"-�L <br /> -3 ` . rCm ; urlsdloutN1To;+be* oaun� or: <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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />