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SAW►JOAQUIN Environmental Health Department <br /> —COUNTY <br /> Greotnns.s grouts herr. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections I and 2. ff your commissary is located outside of San Joaquin County also complete section 3. <br /> !:' 'TP be completed.by.APPLICANT.- <br /> Business Name Lic. Plate# <br /> Owner/Operator Name <br /> . f <br /> Business Mailing Address 9 ILA OL4NV <br /> City <kOL�'- State( AZip 15%-Z"T Bus. Ph._2ro2yS1 -T49.0 Alt. Ph. <br /> I. 4.C11- 60 hereby state that the above information is current,true and correct to <br /> the belt 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 O-L/02,/Z I <br /> E2- To be completed by ff- <br /> COMMISSARY OWN[�R/QPERATOR--.- <br /> Commissary Name �-A­\WW<N­V -v MKX� FA# <br /> Address 2LOL--) t-v­ V-�I4 0,11 57 Bus. Phone 7,01 <br /> City Zip _Owner/Operator <br /> Check all appropriate services provided. <br /> EyWastewater disposal 13 3-compartment sink 0 Electrical hook-ups <br /> 12-IS.olid waste disposal C3 Food preparation M Toilet and handwashing <br /> Q/ lot & Cold water for cleaning [3 Store refrigerated food 13 Potable water <br /> 0 Store dry food/supplies E3 Overnight parking E3 Vehicle wash <br /> 1, 144r�� ZOP6401i , hereby state that the information I have provided is current,true and <br /> corrAt to the best of myknoledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to compl .t, he conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner I ti the EH <br /> Signature Date <br /> 13. To be.com ted—bVTh—eE-E W-HE AL-TH-jurisdidti6hbut9j&i of;.S6n,!J6 W7C6:' <br /> The commissary is loc ted in V 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 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />