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SAN. JOAQUIN Envireydr�Rarantai Heai A Department <br />--COUNTY-- <br />COMMISSARY AGREEMENT <br />Mobile Food Facility 4 Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />11. To be completed by APPLICANT I <br />Business Name IVC)EN A S !Ce Cr'FG. m Lic.Plate# qq 13ZV2 <br />Owner/Operator <br />Business Mailing Address !% d% (Y1 r o N 1 Ci C fi E r <br />City6f-OC L<-t&f A) State eA Zip LaO6 Bus. Ph.2')7-1/.20 -iR %3 _Alt. Ph. <br />1 r7 �4. 4, , hereby state that the above information is current, true and correct to <br />the besarof 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 f9teQv�e L f� G` Dates-gL -.26a <br />2 To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name PIC K N q o lcc c8a:Am FA# <br />Address M r NG Q ave—:' Bus. Phoneae Q— '�kL14'-1 "1 �t <br />City STo C _; Zip CP q Sao s�Owner/Operator �A w <br />OA <br />L <br />Check all appropriate services provided:�y PQ <br />0 Wastewater disposal ® 3 -compartment sink hook-ups x M <br />—Electrical <br />C3 Solid waste disposal E3 Food preparation E3/Toilet and handwashing Z 3 <br />LI Hot &Cold water for cleaning tore refrigerated food Potable water 0 M <br />CI Store dry food/supplies Overnight parking O Vehicle wash <br />WD <br />I, hereby state that the information I have provided is current, true and Ch 6 <br />p M <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 :n <br />commissary owner shall notify the EHD immediately. <br />Signature ��_ �...sl n " \ Date <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 <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 />