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SAN: JOAQUIN <br />---COUNTY— <br />Greotness grows here-. <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />p <br />Complete sections f 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/f7 S Lic. Plate # ZIW KISn <br />Owner/Operator Na <br />Business Mailing Address � <br />ne�Sul <br />City �� r� r State4 Zip9lZ--ar Bus. PhObQ K,7F QUO Alt. Ph.2c>`!- S S Z <br />I, hereby state that the above information is current, true and correct to <br />the best cf4Wy know) ge and agree to utilize my approved commissary in accordance with California Health & <br />Safety Code, and 8A9,Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br />commissary is dis n ' ued, the permit holder must notify the EHD. Failure to notify this offic/mayzresult in permit <br />1 2�To be.e6mpleted by�COMMISSARY OWNER/OPERATOR __1 <br />CommissaryName SrOCKTOV4 CoMtAOULM <tT6A4e,{FA# <br />Address t i O N. EL DORADO ST Bus. Phone <br />City ^Xc)clCM13 Zip GA Owner/Operator LEDltia- CAST1LA o <br />Check all appropriate services provided: <br />® Wastewater disposal ® 3 -compartment sink ® Electrical hook-ups <br />® Solid waste disposal ® Food preparation 51 Toilet and handwashing <br />® Hot & Coldwater for cleaning ® Store refrigerated food 13 Potable water <br />R Store dry food/supplies ❑ Overnight parking ❑ Vehicle wash <br />I, L.EOIJ,� GAs-r(w-o , 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 y with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owAr s II notify the EjjD-iynmediately. , <br />Date 08 1 3o/2Z <br />13. 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 />FF rZ ff.E <br />1868 E. Hazelton Avenue i Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sigov.org/ehd <br />