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SAN JOAQUIN <br /> <br />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 />''illY''..., ,;,-7'; <br /> <br />Business Name ICACOS 'To 1-e --k-Ct,1: Lic. Plate# 354 20L2 <br />Owner/Operator Name CyVir \-S VC/U/1AL° <br />Business Mailing Address W - <br />City 4C1/iA1 State 04-Zip &Bus. P(i510) — 74C(Z. Ph. <br />I, ahrl3d-rov) PAy-Lvce) , 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 t)/ / 712 <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 4i41, ,..V.ArY A74-eet_. FA# <br />Address (6, Z 6 , 5, etC.A-4-14--Liii--- ,f-L Bus. Phone (ie")) Z.Z..9 e3 3 sf <br />City 2-0 0 i ' Zip (- 57 ge.:0 Owner/Operator Aty.frirfr 4-6-I-- <br />Check all appropriate services provided: <br />Ej</Vastewater disposal arc-compartment sink 13'Cectrical hook-ups <br />filolid waste disposal 0 Food preparation Cl/Toilet and handwashing <br />EIK:lot & Cold water for cleaning [24store refrigerated food V3/1;otable water <br />[3-'ore dry food/supplies 0 ,vernight parking PrVehicle wash <br />I, tfrefrii,-‘,. a.:ii__ hereby state that the information I have provided is current, true and <br />correct fo 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 991--77 Date /4 Tr - Z ? <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.orgiehd