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Signature <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />- COUNTY <br />Grto•i7ss qt-ovys <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 />1. To be completed by APPLICANT <br />Business Name 5 4 C. k)C---\-. 0.A3 3 Lic. Plate # <br />Owner/Operator Name.51 5a n (DI €(41 C-eci 17. Con--)-rerez 5 <br />Busi/ntssZing Address 15S k.05C /D4-' <br /> StateCA ZiOC7A3 Bus. Ph. 90 14/ -10 ti / Alt. <br />6LI 34 VI (b 11\--V(Yd eyi V tMi iWat 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 p s. <br />IDate-50q/43 <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 74-e ck._ hz±E- c-044144 , .STDcir Y <br />Address 7 (`J Bus. Phone (701) 7 2!) 3 3 35' <br />City 2-0 ),7 Zip 16z Ye/ Owner/Operator _ <br /> <br />Check all appropriate services provided: <br />El Wastewater disposal ja-3-compartment sink 13 Electrical hook-ups <br />la Solid waste disposal 0 Food preparation El Toilet and handwashing <br />& Cold water for cleaning 0 Store refrigerated food ta-Potable water <br />El Store dry food/supplies CI Overnight parking El Vehicle wash <br />7 1erfA- , 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 END immediately. <br />Signature z---Z---6<<- <br /> <br />Date 3 <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 952051 T 209 468-3420 F 209 464-0138 I www.sjgov.org/ehd <br />FA#