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SAN JOAQUIN <br /> <br />Environmental Health Department <br />—COUNTY-- <br />G-tncs her- <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 Croi-- e)1=7- 1,:re Lic. Plate # 1137 C 144 <br />Owner/Operator Name r ,S;r1414 <br />Business Mailing Address /6 tHt3T4tk Lao ;- <br />City lAtViVO State (a Zii -511.1§1Bus. Ph. 7A4 1-16.5 4417 Alt. Ph. "Ibq 6/4i A6-74 <br />I, i..14,t-e4 V" , 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. <br />Signature I 1.13:21 Date <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name P q 0 FA# <br />Address 3`-iI L (14 /' VC' 3V& Bus. Phone kA c' <br />City _C7-0 CK -7-thezv• Zip GA el cc Owrfl 'erator <br />Check all appropriate services provided: <br />Wastewater disposal <br /> <br />CI 3-compartment sink <br /> <br />VVElectrical hook-ups <br />Solid waste disposal <br /> D Food preparation <br /> rirr-oilet and handwashing <br />Hot & Cold water for cleaning <br /> 13-5fore refrigerated food <br /> • Potable water <br />Store dry food/supplies <br /> ErOvernight parking <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 S:7‘7.47,-4,--,-, <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 />RENS Signature Akelz-titi2.---- Date 3-31 2-3 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I 1 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />Date