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S A N J Q AQ U I N Environmental Health Department <br /> —COUNTY— <br /> Greotnes> <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 ARWICAN J <br /> Business Name;? 14)Pt 11 , aFoo D Lic. Plate# `?�$t/U� 3 <br /> Owner/Operator Name 6M(YiAm_ 91 K (Y)A(> A N <br /> Business Mailing Address'Ll G 7 Z R(,?V rntXLA6( P f C k,t7 nr <br /> CityZA�-Hrr, _States ZipJS71�(-.) Bus. Ph. 70q -378-56146 Alt. Ph.'/�d4 - L 3o-2129_ <br /> I 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 /> Signatur - <br /> �r� <br /> Date iv'i7-2 <br /> 12,T be com leted b. .CQW16MRY,f0R <br /> Commissary Name Lk( t I P 1J A [ER I AG TRUCK CC(STEP- FA# <br /> Address l 7f 7 LS, LIAlt0,&( ST Bus. Phone,. a`-(� .2, <br /> CitySTbL. 6Il� { <br /> CA Zip CiS265' Owner/Operator ! I KA 4 <br /> Check all appropriate services provided: N.6 5 Tk�.Rv%< ,t <br /> dwastewater disposal ❑ 3-compartment sink ❑ Electrical hook-ups <br /> [Solid waste disposal ❑ Food preparation ❑ Toilet and handwashing <br /> ❑ Hot & Cold water for cleaning ❑ Store refrigerated food 0"Potable water <br /> ❑ Store dry food/supplies ❑ Overnight parking ❑ Vehicle wash <br /> 1, &E( 7/1u?ejJ , 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 omediately. <br /> Signature wrc E- Date l413 <br /> 13.1T, be'c:om lee l the ENV HEALTH Ul7sdiction outside of.San Jpa:'uI CQ.`L <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 />