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, 'PO°INr SANAOAQUINp <br /> Environmental Health Department <br /> —COUNTY <br /> C' 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 /> Business NameEI_ C1leili III h0 Lic.Plate#. �g3�Ialx� <br /> Owner/Operator Name 71 X1645 C2 I I PlAV S C+1H S <br /> -Business 6b)(Mailing Address PI? 6b <br /> M� 1 <br /> city 5 t W'N State N Zip il SZ05Bus. Ph.'U'l 31 VAlt. Ph. 101 ' u Bj� <br /> I,Wd1 FSG iSL�o 1(q F Flas <br /> COO O1 h�r7l`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 pltie�/� 9 <br /> Signature `/ �) Date <br /> itTo om`,Leted b ,,.C.QMMIS,SARY OWNER/OPERATOR : ' <br /> CommissaryName P1 FA# <br /> Address. ,IAd,o_l' I,) . L oyL5VTCtj Bus. Phone 2-0'1"A� 1 _ 3 1 q✓ <br /> , 'my <br /> City `� Zip 152-0Owner/Operatorfol✓1CfSCI) 11AW s 6WY��1S <br /> Check all appropriate services provided: <br /> d Wastewater disposal Pl 3-compartment sink CS Electrical hook-ups <br /> [1f Solid waste disposal d Food preparation G(Toilet and handwashing <br /> p Hot& Cold water for cleaning 0 Store refrigerated food Ef Potable water <br /> ut Store dry food/supplies /� Cr Overnight parking [Vehicle wash <br /> 1,�161VrICl SCD 110013COWAS 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 o �r shall /notify EHD immediately. �1 j <br /> Signature —Date 0 1-2 - _Z5 <br /> 3. To b'e coin. leted b the ENV'HEk 'urisdictio . <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 evailable 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 /> d <br />