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NaUltv <br />2. <br />sA N r .j0AQUIN <br />< " VCOUNTY <br />. • 47. Greatness grows here. <br />Environmental Health Department <br />the best of my knowledge and agree <br />Safety Code, and San Joaquin Cour <br />commissary is discontinu , the p <br />revocation and penalties. <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 />I. To be completed by APPLICANT <br />Business Name (40-9zmi BY <br /> <br />Owner/Operator Name M (-7)-1 /V C4 1-1 <br />Business Mailing Addrpss c3 3 4o I-0)LX CT <br />CityD/&bc (412A-lbd tgtate CAZip C1C36, Bus. Ph. 20 `0 I LI (19 33 Alt. Ph. q Ls-go 0 0 00 ci <br /> , hereby state that the above information is current, true and correct to <br />utilize my approved commissary in accordance with California Health & <br />Environmental Health Department (EHD) requirements. If the use of the <br />holder must notify the EHD. Failure to notify this office may result in permit <br />Date Oi I 420 2 3 Signature <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />20q) 22'4-833c/ <br />City Zip q2,k-,1 0 owner/operator 11-4,A0Acko Dalai /Nalail ETACC,(q C.C.3 4\ <br />Check all appropriate services provided: <br /> <br />Wastewater disposal ,111-compartment sink 0.' Electrical hook-ups <br /> <br />?q Solid waste disposal (--ood preparation KToilet and handwashing <br />\-0-Hot & Cold water for cleaning /6Store refrigerated food ,EF Potable water <br />,crStore dry food/supplies g Overnight parking ,...,Vehicle wash <br />M,c,CC 'N-0;tcC)1 , hereby state that the information I have provided is current, true and <br />correct to the best f 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 /> <br />commissary owner shall nu t EHD immediately. <br />Date <br />,-- <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 1 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />Lic. Plate # 11% y .7 :3 7 <br />Commissary Name LOO\M\c-aif FA# <br />Address (4)20 b.c>occopmA\ Bus. Phon <br />Signature