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S?J(jAQIN Environmental Health Department <br />--COUNTY--- <br />Creonass grows hern, <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 <br />Business Name kA Y1 ,C- C- �S S tc CC -T 0L4rV ITAS Lic. Plate # '(5/k ?1"/-3 <br />Owner/Operator Name0'(65A]UE- 5497' s <br />Business Mailing Address S, c R R o c i_ LI• <br />City'52C1%©(u/ Stated Zip95Wt5 Bus.PhPOVC'Ir/-�7�,3 Alt.Ph. <br />I, 13 `; ft0 851`06; -T R (v`T05 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 older must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name u N (0 0 CI1d& %liuLk C�Niz-ER FA# <br />Address 17/ 7 S, U(61/w,' ST Bus. Phone(zo9) Z �S"Sys 6 <br />City � C�. C/� Zip 52o G Owner/Operator R/i r �RAOc <br />Check all appropriate services provided: <br />"astewater disposal MI -compartment sinklectrical hook-ups <br />MlSolid waste disposal l9/Food preparation 13/ Toilet and handwashing <br />Itis Hot & Cold water for cleaning MStore refrigerated food tf Potable water <br />Store dry food/supplies WOvemight parking a/Vehicle wash <br />I, /�R% -71—NIVO 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 oti the HD immediately. ,\/ <br />CinnaT��rw i Date �' 3``r � Z) <br />3. To be.com leted 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 wwv✓.sjgov.org/ehd <br />