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4, SAN JOAQUIN Environmental Health Department <br />—COUNTY -- <br />^'f 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 kZc,MAl t(` rz- Lic. Plate# U73(0 [V f <br />Owner/Operator Name R -LB(- S � )\q�L . <br />Business Mailing Address U 66�, lk wf11 _ C <br />City ��(.k.W 5tateA�[C ZipuS Bus. PhCpq 1 QIt. Ph. <br />�A <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 />2. To be completed b COMMISSARY OWNER/OPERATOR <br />Commissary Name R..ctc_ �1 66 i{e. Cee -w` FA#. <br />Address -3i412— E yt1'.w« w Bus. <br />City OacKlo Zipqs-2,0 - ew erbperato <br />Check all appropriate services provided: <br />p Wastewater disposal 13 3 -compartment sink <br />E3 Solid waste disposal 13 Food preparation <br />0 Hot & Cold water for cleaning 91�-More refrigerated food <br />G Store dry food/supplies Ulr6vernight parking <br />Phone 2E)cj- i l 1.1 Lr <br />ILalectrical hook-ups <br />Ia,ToTlet and handwashing <br />13 Potable water <br />0 Vehicle wash <br />to <br />O <br />n <br />X <br />i <br />z <br />0 <br />A <br />I, hereby state that the information I have provided is current, true and <br />Ch <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facilityN <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, theO <br />commissary owner shall notify the EHD immediately. <br />Sig <br />af.,R2 <br />3. To be completed by the ENV HEALTH jurisdiction outside of Sap Joaquin Go. <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 Signatu <br />b <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 />