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°'�v SAKJOAQUIN Department <br /> Environrnenta! Health <br /> " 1 TT%.-�1 —COU NTY— <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 /> 1. To be completed by APPLICANT . 21 <br /> Business Name KHi5i <A (- 'ICE r-,Q)f 4 rj Lic. Plate# D3^l <br /> Owner/Operator Name KALI P f3jq Z t.j A NT" <br /> Business Mailing Address I ca I a 9 A6 c— kw HAr -L36 iQ P—h <br /> City La-rHRoState-". Zip c3g0 Bus. Ph.�� 34e -uth�kAlt. Ph. <br /> I, , hereby state that the above information is current,true and correct to -4 W 0 <br /> the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & O '_'�L` X <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the n N Z <br /> commissary i ntinued,the permit holder must notify the EHD. Failure to notify this office may result in permit 7, M <br /> revocatio nd pen ties. qq""QQ \ Q O <br /> ure <br /> Signat1 ' Date �ot' orqqi- 094090 _ Zm <br /> com <br /> 2. To be.com feted by COMMISSARY OWNER/OPERATOR m D n <br /> (.SCM <br /> Commissary Name C1< � qy %C C-geArn FA# m m <br /> Address 31-11 k� E• M; r✓ L R 9VF Bus. Phone <br /> City S %v fX rc.✓ Zip cp gs1z.)z?s- Own r/Operator N <br /> Check all appropriate services provided: 1 A y <br /> E3 Wastewater disposal 0 3-compartment sink \'�-{3 Electrical hook-ups <br /> 0 Solid waste disposal O Food preparation t.;l Toilet and handwashing 0 (� <br /> 0 Hot & Cold water for cleaning �'Q Store refrigerated food 0 Potable water Z Z C <br /> 0 Store dry food/supplies Overnight parking 0 Vehicle wash D M <br /> I, hereby state that the information I have provided is current, true and D <br /> correct to the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility N C <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the p R1 > <br /> commissary ownershallnotify the EHD immediately. N _31 <br /> Signature ��� , Date '�k\— <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 I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />