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SAN JOAQUIN <br /> <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 />.AdAPVti <br />Business Name <br /> <br />Pf--2261 <br />dvard 67 <br /> <br />Lic. Plate # 4-1 3 6‘ <br /> <br />Owner/Operator Name <br /> <br />Business Mailing Address 5 7 ctiet44y Dr <br />City IA+ State Cft zip c Bus. Ph. 020(0 9655-2 igAlt. 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 END. Failure to notify this office may result in permit <br />revocation and penalties. ' <br />Signature <br />z ate completed by.:C000_66MY OVVIsIER/OPERATIEN <br />Commissary Name A 7--W-A- Zekt444 FA# <br />Address 62e, 5 AG ii? Bus. Phone (409) 3Y-/ <br />Date 0 3 )3 <br /> <br />City L.4 0 , Zip q 5 ;Z % Owner/Operator <br />Check all appropriate services provided: <br />[2Wastewater disposal L., 3-compartment sink <br />SI/S'olid waste disposal Food preparation <br />ai-l-ot & Cold water for cleaning a/ re refrigerated food <br />Store dry food/supplies Overnight parking <br />fikfriire) OCkice,_ <br />digctrical hook-ups <br />"Toilet and handwashing <br />074otable water <br />Vehicle wash <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 />Abe.mostecti.limittin . <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 />RENS Signature Date <br />1868 E. Hazeiton Avenue Stockton. California 95205 T 209 468-3420 i F 209 464-0138 l www.sigov.crglend <br />Date 3 s-a4/ -2 3