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SKJOAHIN Environmental Health Department <br /> —COUNTY— <br /> Greatness grows here. <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 a. 75, Ragan 1C'E CRF A&4 Lic. Plate# Klf� 8 <br /> Owner/Operator Name C 0 K to P-is T S 1_ N(Zc 44 lin&pk <br /> Business Mailing Address yt)38' ag", jzo4d <br /> City.Ll Lt-e� State Q�'�..Zid��Bus. Ph.�20 9� �1 gI-7�l'� Alt. Ph. <br /> 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 holder must notify the EHD. Failure to notify <br /> /this office may result in permit <br /> revocation and penalties. /2vZZ <br /> Signature Date �1 <br /> 2. To be completed by COMMISSAR�Yf OWNER/OPERATOR <br /> Commissary Name 1V 1 C n TV g O �/ C C C I, E p (i,'FA# <br /> Address 2 L ) a C, M i fV ER P V L. Bus. Phone_dccl- (�t�-kS' - I� � q <br /> City S i o CJc To h/ Zip cA 01 52.05 Ow er/Operator o W n,- E q, (A4f 00 <br /> Check all appropriate services provided: A 0 <br /> E3 Wastewater disposal O 3-compartment sink Q�Electrical hook-ups t7 N Z <br /> p Solid waste disposal O Food preparation D'Toilet and handwashing I1n G) <br /> Oo <br /> E3 Hot & Cold water for cleaning C-Store refrigerated food a Potable water Z Z <br /> n <br /> 0 Store dry food/supplies 03-Overnight parking E3 Vehicle wash D M MI, hereby state that the information I have provided is current,true and t0 D <br /> correct to the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility Nm <br /> operator fails to comply With the conditions of this agreement, or if this agreement is modified or cancelled, the O m <br /> commissary owner shall notify the EHD immediately. O ic <br /> Signature r 'A64_„ � "1, '_.,�^ Date 14– t 7-- `� L <br /> e_j <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 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 />