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SAN J OA Q U I N Environmental Health Department <br /> CCs U rlv 'T y <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 /> Business Name T <br /> ACOS Zr_ L AIJIFIZL Lic. Plate# 7T.i3 1933 <br /> Owner/Operator Name C IOA MeL o 6A{ 7_191\1 <br /> Business Mailing Address 3 4111 , MR 9 V A V <br /> City 6J t&Ck.To nl State LAZip 5�o r; Bus. Ph �.37,327��gg3 Alt. Ph. <br /> I,- C H R IM F L d N Tji ll.) , 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 pejYties. <br /> Signature L1 1, Date /.Z 12-d Z(3 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName [r1 IPO D IIJ C61FRIAI& %bu c k CEn/7EA FA# <br /> Address . G(/&OP, S f Bus. Phone a) 210' -Sy/ 6 <br /> City sTd c �1�N CR zip a0 6 wner/Op re a ort K�l l(Alf e b Q Q <br /> Check all appropriate services provided: ' <br /> 'Wastewater disposal 13 <br /> 3-compartment sink Electrical hook-ups <br /> Solid waste disposal Food preparation 14"'Toilet and handwashing <br /> GF'Aot & Cold water for cleaning GYStore refrigerated food 0-'Potabie water <br /> Ca�tore dry food/supplies Overnight parking r9"Vehicle wash <br /> I, / /L I l 1CuD# y , 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 all notify th HD im ediately. /-'�Signature Date I 6 2(3 2 y <br /> 3. 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 1 Stockton, California 95205 I T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />