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SANIOAQUIN <br />tinr''r --COUNTY-- <br />Greatness <br />-COUNTY-- <br />Greatness grows here. <br />EnArronmental Health Department <br />COMMISSARY AGREEMENT =` 1 <br />Mobile Food Facility o Caterer I. ,. <br />Oliver T * w <br />Com ms...y <br />145 . Kilroy Rd <br />TW1Q k, CA 953U <br />21394844M <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 cA 5' �7 Lic. Plate # 467e, 3 <br />Owner/Operator Name Q z&'O' ��ru �Sa �^ P �Q <br />Business Mailing Address 45,0o -4 <br />City eTZ,TStatef�ZipJS3T7 Bus. Ph. z09.4D7Alt. Ph. IVIA <br />IV <br />I, — hereby state that the above information is current, true and correct to <br />the best of my knowledge nd 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 />2. To be completed b COMMISSARY OW/NER//O�PERATOR <br />Commissary Name P) //_e raS _D;_ -,A, �1-,o/_ ( Gp7,,0/ JF A4V <br />Check all appropriate services provided: <br />(JFWastewater disposal lf�' 3 -compartment sink <br />Z Solid waste disposal F" Food preparation <br />Hot & Cold water for cleaning V Store refrigerated food <br />1)6 <br />D/!5 <br />0 Electrical hook-ups <br />0 Toilet and handwashing <br />RT Potable water <br />Z Store dry food/supplies, rj Overnight parking � Vehicle wash <br />I, r� ✓Y✓I4 1W�•� ✓�� , 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 99i*Pe EHD immediately. <br />i / y <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.sigov.org/ehd <br />