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"c SAKd0A0UINp <br /> Environmental Health Department <br /> COU NTY <br /> �r ,r c,Fo0 Greatness grows o 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 /> 1 . To be completed by y) <br /> APPLIICANT � <br /> Business Name (7) P1I 1 I IICE, C�E- h-) Lic. Plate# 6 <br /> Owner/Operator Name ffiM F-1 `C `-/ S ' t) I Yy I <br /> BusinessMailingAddress 1-1 �' kE Niy y - <br /> City S�}oC.11-- CI / , StateL:A Zip Gly Zf Z Bus. Pl­( O°�) 0_�P0 Alt. <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 R 1^rn2q 19' S Iy I Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name f i C K t1/ 5-0 CR(_ FA# <br /> Address 3'v( I G n-7j'a3��,C-RV L- Bus. Phone sol^ °tom VI <br /> City STa C'Cc �br,,/CeZip Owner/Operator ryS'� O'V 6 2a 5A /V j <br /> Check all appropriate services provided: NI- <br /> 13 Wastewater disposal 133-compartment sink M. Electrical hook-ups <br /> p Solid waste disposal E3 Food preparation Toilet and handwashing <br /> 0 Hot & Cold water for cleaning \� Store refrigerated food 13 Potable water <br /> 0 Store dry food/supplies m Overnight parking o IRCKWI O ICE CREAM <br /> IlVyj•, hereby state that the information I have pr i mew" <br /> correct to the best of my knowledge,and meets the California Health&Safety Code req I 05 <br /> operator fails to comply with the conditions of this agreement, or if this agreement is ie �,o <br /> commissary owner shall notify the EHD immediately. —OCK-fON, CA 95205 <br /> Signature 6;�" & Date a--_'� ,(— � <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in I 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 />