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SAN IOAQUIN Environmental health Department <br /> --COUNTY— <br /> : <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility t Caterer <br /> Complete sections 7 and 2. If your commissary is located outside of San Joaquin County also complete section 3- <br /> 1. To be completed bAPPLICANT <br /> Business Name 11/i L('1 ri 4RI P / Qd,/ Lic. Plate# 3235693 <br /> Owner/Operator Name Ckk'IQuc ,OPDWRd <br /> Business Mailing Address •33 7 �. 7-171S ST, <br /> CityS VKTO� StateCA Zips Bus. Ph(e1)$Yg-2YS7 Alt. Ph. <br /> I, to R t Ix iCc AG 0L e o 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, they permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature e05�rt Yl A G✓yt P'07 i Date t//✓°-/-2 2- <br /> 12. To be completed bCOMMISSARY OWNER/OPERATOR <br /> CommissaryName Uk"IC0/ll C-d7U(46 k4Ck (-60-6P FA# <br /> Address <br /> 7/7.5. uAlted 5-r Bus. Phoned 4) -:7 5ffell <br /> City,j/GCk&A, Gtr Zip ?,5.2 b 6 Owner/Operator imf �iefJUt•' <br /> Check all appropriate services provided: <br /> W�Vastewater disposal JU 3-compartment sink 11/ ectrical hook-ups <br /> OKS'olid waste disposal M—food preparation 1 Toilet and handwashing <br /> CKiot & Cold water for cleaning Ottore refrigerated food (Potable water <br /> arstore�rdry food/supplies 13-Overnight parking ff Vehicle wash <br /> I,�1 l ! //tl fipo , 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 shall noti he Efjp immediately. ��/S 6) <br /> Signature /.L C �. G% Date e L l <br /> 3. To be completed bthe ENV HEALTH jurisdiction outside of San Joa uin 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 />