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$QK:.jQQUIN Environmental Health Department <br />—COUNTY <br />COMMISSARY AGREEMENT <br />Mobile Food Facility a Caterer <br />Complete sections land 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1, Ta be calm letedb PLfCANT <br />Business Name ir)Af Lic. Plate # %) 0. � <br />Owner/Operator <br />Businesp Mailing Address <br />City „ � <br />/ StateZip S Bus. Ph�O%-cf S S /� �/b3 Alt Ph. <br />I, L1q S'l / U hereby state that the above information is current, true and correct to <br />the best dir my knowledge and a me to utilize my approved commissary in accordance with California Health & <br />Safety Code, a an oaquiif qunty Enviro a taI Ith Department (EHD) requirements. If the use of the <br />commissary i disconti ued the i holde u n e EHD. Failure to notify this office may result in permit; <br />revocation a d penalties. <br />Siqnature Date <br />12r To be' completed: by COMMISSARY OWN[ -- RtOPERATOR <br />Commissary Name LA FA# <br />Address OfAC E )iAWrAwn5 Rina Bus. Phone_ OA(A " <br />C ity ��U Zip tlS Z05 Owner/Operator C1r\: o _ Acne, -}-k <br />Check all appropriate services provided:: <br />Wastewater disposal 3 -compartment sink <br />/olid waste disposal es Food preparation <br />Hot & Cold water for cleaning ® Store refrigerated food <br />M9ft-tre dry fc <br />G _ <br />correct to the <br />operator fail: <br />L-2 'Overnight parking <br />Electrical hook-ups <br />��T "let and handwashing <br />prtable water <br />Vehicle wash <br />TAIA G -z , hereby state that the information I have provided is current, true and' <br />knowledge, and mpo the California Health & Safety Code requirements. If the food facility <br />wrfh the Gond cis of this agreement, or if this agreement is modified or cancelled, the <br />notify the immecrlately. ;- <br />Date //- /D - J d -�/ <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 />1:44.5.1 <br />1868 E. Hazelton Avenue I Stockton, Carriomia 952051 T 209 468-34201 F 209 464-0138 1 www"sjgov"orglehd <br />