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OSAN4 AQUIN <br />!soli COUNTY — <br />r <br />‘‘, <br />Environmental Health Department <br />Greatness grows here <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 />1. To be completed by APPLICANT <br />Business Name <br />, , <br />15 v.-I -Atan-ens Lic. Plate # <br />Owner/Operator Name <br />Business Mailing Address NI 7 g '-feyre(&04,:v 6' ty <br />City "-; -6)&6;9 StatelAZip 9 C >(tBus. Ph(Th 9)L4#o h Ph. <br />/"\j"-- hereby state that the above information is current, true and correct to <br />the best of my k owledge 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 <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name de/211-CW t'kyikti ekm5 <br />Address 27Zi -Ci S. &v.; /d 13 -61e,/ Bus. Phone <br />City (?f Zip 512 q 2_ Owner/Operator <br />Check all appropriate services provided: <br />pit 3-compartment sink <br />)0 Food preparation <br />)2( Store refrigerated food <br />0 Overnight parking <br />Date <br />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 Califomia Health & Safety Code. The above checked services are available at the <br />above commissary. Please notify END if the status of their operating permit changes. <br />RENS Signature Date <br />Wastewater disposal I <br />Solid waste disposal <br />y4 Hot & Cold water for cleaning <br />X Store dry food/supplies , <br />(7,-/k a v litc - 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 notify he EH immediately/ <br />Signature g (?. <br />FA# r --ficoozpei)G-37 <br />)oci oc 3 -6207 <br />vtd_141c- <br />'Electrical hook-ups <br />)4 Toilet and handwashing <br />frf Potable water <br />0 Vehicle wash <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209468-34201 F 209 464-0138 1 www.sjgov.org/ehd