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SANJOAQUIN <br />ttilig* —COUNTY <br />0"162e":5- r -10Foso ,Jreatness grows here. <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility. Caterer <br />Complete sections 1 and 2. If your commissaty is located outside of San Joaquin County also complete section 3. <br />To be completed by APPLICANT <br />Business Name k S C42 G:f4 (Y) <br /> <br />Lic. Plate # SR 1 5)s7 <br /> <br />Owner/Operator Name CI' t't R -s' nig (-I 11 sq6). <br />Business Mailing Address \46 ( L -re-73 DR <br />City fyi 0.N --r F cp State co Zip qg -ss--1 Bus. Ph. c-V-y ki\ 1`-,‘ Alt. 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 />Date 'VI' - V\-- " <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name CPI(' IS. W q' /cc cicY FA# <br />Address 39 j /v. c-q ,iq YL Bus. Phone <br />I:1 Wastewater disposal 0 3-compartment sink -NCI Electrical hook-ups —I • m 0 <br />Solid waste disposal 0 Food preparation -1:1. Toilet and handwashing 0 <br />City S z cr Zip c? 015.--A0 s - Owner/Operator tpi (-3 <br />Check all appropriate services provided: <br /> 0 - <br />x Z <br />E <br />11 <br />Hot & Cold water for cleaning N0 Store refrigerated food 0 Potable water 0 M 0m <br />-.....,.... > X <br />Store dry food/supplies 0 Overnight parking 0 Vehicle wash 0 <br /> hereby state that the information I have provided is current, true and 01 < NI rn P correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility 0 !" > <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the t" E <br />commissary owner shall notify the EHD immediately. <br />Signature 17' .74 Date / — <br /> <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 />RENS Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />1, <br />Signature