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Lic. Plate # 5 33 $-30 <br /> <br />A f t r_ <br />' <br /> <br />Alt. Ph. <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />9 vv's <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 />1. To be completed by APPLICANT <br />Business Name kcisockcos L1.)c)k - <br />Owner/Operator Name A nd lea <br />Business Mailing Address iG ( 5 7 0\ \ <br />City -"-Cr-cvc State A Zip 3 -1,6 Bus. Ph. <br />1, Pt in <br /> <br />d\( O. 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 penalties. <br />Signature l'‘nc\c- LI,R7 <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Za //15ariG 1,066i4) <br />Address 12-1 t S Bus. Phone OM 33Y -3 ‘,6 3 <br /> <br />City ocie.si-o Zip Q 535i <br />Check all appropriate services provided: <br />'Wastewater disposal <br /> <br />12K:compartment sink <br /> <br />CYllectrical hook-ups <br />1:14;-od preparation <br /> E3Toilet and handwashing Solid waste disposal <br />refrigerated food .41 Pable water & Cold water for cleaning <br />In'Overnight parking <br /> 0</ehicle wash E'ore dry food/supplies <br />Atirh 0.-5 64e , 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 />all notify the EHD immediately. <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 Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I vvww.sjgov.org/ehd <br />Date <br />FA# <br />Owner/Operator Cold 51-ort)ye. am.,„.„.550 v, /pi& <br />commissary owner <br />Signature Date 6A72 5