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SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />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 />To be completed by APPLICANT <br />Business Name ThCa5 ef -Z. PR/11,0 04fiRLie Lic. Plate # 3 7SR 2 <br /> <br />Owner/Operator Name (Air UCA- firM <br />Business Mailing Address -/(7i3 6 1-e--,2o r0 <br />City St0j-to v\- State CIA Zip 9 c 0 -3- Bus. Ph. <br /> <br />Alt. Ph. <br /> <br />I, /34' . LA, SUCAP2 , 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 pena ties. <br />/3L(2L Signature cgt" Date <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name (kik!' ( b Al C fir-ER c 1(; GI --R uzi<- <br />Address i 7/ 7 S, z(4// 641 -57-, Bus. Phone 0 ?). M3* <br />City 57":66m(0, Cil Zip ?:5-07601(i Owner/Operator 0 il)ltrek <br />Check all appropriate services provided: <br />,.., ..7 <br />a'Wastewater disposal 19- 3-compartment sink El Electrical hook-ups <br />UrSolid waste disposal CYFood preparation tr-'1oilet and handwashing <br />a Hot & Cold water for cleaning Ur <br />,, <br />Store refrigerated food I7,4otable water <br />,./ <br />DrStore dry food/supplies 10' Overnight parking 0 Vehicle wash <br />I, VT— 77/WO , 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 s II notify the EHD immediately. , <br />Signature ,<----i --1.0 Date //3C Z2 C 2_ 3 <br />To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. 1 <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 />REF'S Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd