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SAN JOAO,UIN <br />f/e °5-- Z/i4e <br />Environmental Health Department <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 />t Tecte completed INAfftlaNNT <br />Business Name 322 61 Lic. Plate # p(-7 <br />Owner/Operator Name (iVard 0 67 C/214/e-ci <br />Business Mailing Address 5. 7 tOotkul Di- <br />City 6a-1-- state CA_ Zip c C3 Bus. Ph. (20) 9 6_3 5-2 iq Alt. Ph. <br /> 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.,,/, Lfrt.01 <br />Signature Date <br />2. To be compieted by COMMISSARY OWNER/OPERATOR <br />Commissary Name C(.,koni FA# <br />Address 62e, 5 -7Acv-tao-piprie cf Bus. Phone (229) 2- ZY, 3Y/ <br />City L-c' Zip 15 ;2 YO Owner/Operator <br /> <br />Ne)ewir.0 0( yip eL. <br /> <br />Check all appropriate services provided: <br />/Wastewater disposal <br />gVS'olid waste disposal <br />Hot & Cold water for cleaning <br />3'ore dry food/supplies <br />1, <br />3-compartment sink <br />6 Food preparation <br />a/ 'b re 1 re refrigerated food <br />Overnight parking <br />4ctrical hook-ups <br />in"Toilet and handwashing <br />024table water <br />2"Vehicle wash <br />7±cci-- <br />Date 3 •-at.) -2 3 <br />, 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 shall notify the EHD immediately. <br />Signature <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. Hazetch .A.vehJe Stockton. California 95205 T 209 458-3420 F 209 464-0138 www.si,gicv.crci.eht