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1, <br />SAN JOAQUIN <br />COUNTY <br />Greatness grows here. <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 />To be completed by APPLICANT <br />Business Name -A /9_5 c E r/i <br /> <br />Lic. Plate # 1 9 7/1 V <br /> <br />Owner/Operator Name r loyAmmAp A-s) <br />Business Mailing Address 1,6 9 _ AA/ 7.7:i '77D -I9Z- <br />City ii-eirKre-vii State c AZip Yhqs:Ci Bus. Ph. j o ?-2-7179o4 Alt. Ph. <br />fk (A(1&% ;1() , 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 penaltie <br />Signature <br /> <br />Date _a --,,2_1)2 <br /> <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name (12'ic K GO it (.; ),Y-1 <br />Address 1:4q-/...I FeiSi IV) i_ricor A Lto Bus. Phone <br />City rc 0-6 rt Zip CIS ?,..0 5 Ow446/Operator <br />Check all appropriate services provided: <br />Wastewater disposal <br /> O 3-compartment sink <br />El Solid waste disposal <br /> O Food preparation <br />W 'tore refrigerated food Hot & Cold water for cleaning <br />a-Overnight parking Store dry food/supplies <br /> , hereby state that the information I have provided is current, true and cen <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility K1 rn <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 ,wir <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 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />FM <br />Eallectrical hook-ups <br />Wrfoilet and handwashing <br />0 Potable water <br />CI Vehicle wash <br />Date <br />U) :2 •••I V 0 <br />ra. X <br />Nrn z- <br />-4 • <br />3 0 <br />E 0 rn m <br />0