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SAN- J OAQ U I N Environmental Health Departmer <br />---COUNTY— <br />,,.t surncsr. crow, hpre. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o 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 completed1b APPLICANT <br />Business Name C-1AerkcCPnO Lic.Plate # <br />Owner/Operator <br />Business Mailing <br />n In-Crnca' , ci t 2SS <br />fJ o -e <br />Ph. 21Oq 32't _iCEBAlt. Ph. Y a� C_ -(f <br />r <br />I, , .. , rpt. (n CAJP.Y/1Uy)2+e2_ ,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, Ahe permit holder must notify -the EHD. Failure to notify this office may result in permit <br />revocation and penalties _ <br />Signature L ,'tA Date , I 102,_5 <br />12. To comple%d-by COMMISSARY OWNER/OPERATOR d <br />Commissary Name L/4a Irlr �1A jw�©od f_,rA Z$ FA# <br />Address 1 (D,2 Qd Hj 1- Va r4 R8- Bus. Phone_,201 - 71 7 r �4e Qlo <br />cityW bcoa Zip 9_6; �Owner/Operator 5ib".tr RorW1S. St <br />Check all appropriate services provided' Il" <br />,(Wastewater disposal ❑ 3 -compartment sink CII/Electrical hook-ups <br />Solid waste disposal C1 Food preparation O Toilet and handwashing <br />❑ Hot & Cold water for cleaning ❑ Store refrigerated food VPPotable water <br />❑ Store dry food/supplies Overnight parking a Vehicle wash <br />I, ��( MS< hereby state that the information I have provided is cur ent, true and <br />correct to the best of my knowledgef 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 own hall not}ie EHD immediately. <br />c;...,�r, ��o _!//K/ Date <br />3. To b completed by the ENV HEALTH iurisdiction 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 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www-sjgov.org/ehd <br />)e --MA t ) 4 <br />