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SAN,d0AQUIN Environmental Health Department <br />--COUNTY— <br />Greatness grows here. <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 1.0 S Provicionc Lic. Plate # <br />Owner/Operator Name 1) (4\pif,1 Co r -r-c <br />Business Mailing Address 10 H ouvi Lan e, <br />City LD 6,1 State CA Zip Cl 5 4 -Bus. Ph. 2_0a1*.-131 099Alt. Ph. 5-0a1 .1-77 I 77 <br />1, Pa n \ ()Jo vt-u, <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name I Z1L"e(e( FA# <br />Bus. Phone (2 ? ZZY^ g:55Y <br />City 2-6 171 Zip 115-27 <br /> <br />Owner/Operator A/e14110-0 <br /> <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. <br />Signature Date 3 / 2_6 I 23 <br />Address <br />Check all appropriate services provided: <br />rjrWastewater disposal <br />Cl/gold waste disposal <br />dr<lot & Cold water for cleaning <br />04tore dry food/supplies <br />01-‹-compartment sink I, Food preparation <br />04tore refrigerated food <br />raKC ':ivernight parking <br />tdlectrical hook-ups <br />0/Toilet and handwashing <br />OF,table water <br />a"Vehicle wash <br />,47 -1--ez , 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 Date 3 - <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 Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd