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-`_ 3AIUMAUUM cnvironmentai neann uepartment <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 a <br />1. To be completed by APPLICANT <br />Business Name / an &n(f 690 Lic. Plate # q 11 13 bG� <br />Owner/operatorName^C;iTti'A' <br />Business Mailing Address b f Zee - <br />city G Ocif StateG Zip Bus. Ph_109-32-7'13 Alt. Ph <br />I,'— F� tTL✓� , 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 this office may result in permit <br />revocation and penalties. <br />""),d _ <br />Check all appropriate services provided: <br />g Wastewater disposal <br />X 3 -compartment sink <br />Ni <br />Electrical hook-ups <br />WX Solid waste disposal <br />A Food preparation <br />K <br />Toilet and handwashing <br />K Hot & Cold water for cleaning <br />X Store refrigerated food <br />R, <br />Potable water <br />,,, Store dry food/s,,/u/p��plies Y Overnight parking i,?" Vehicle wash <br />I,\, M H14 /7iK �{/% r//S 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 co ply with the. condltion of is agreement, or if this agreement is modified or cancelled, the <br />commissary own shall notify the EHD ' i ely. <br />_ <br />3. To be comp feted by the ENV HEALTH jurisdiction outside of San Joa in Co. <br />The commissary is located in G1C `G Y1 C col '1,Ako 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�l Date ? C ! <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.orglehd <br />