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• <br />1. SAN...JOAQUIN o, <br />COUNTY-- <br />Environmental Health Department <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 A tAttkl(stt c6k-t(e_, Lic. Plate # <br />Owner/Operator NameAc‘i(r JUne <br />Business Mailing Address HL1 5 N. Lo rtte ( t <br />CityTtC1CJ1 Statera Zip cicj?)cii Bus. Ph. 'Wci -BiLl )35'- Alt. Ph. <br />I, Aoqn io \-)e& 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 CAAT- /AU- <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Lo Ciorvols aria /6(ocies -i-c, <br />Date <br />FA# <br />Z3 <br />Address 121\ S Bus. Phone (o)33 -36' <br />City M Ocie, 5)-0 Zip cis 7,5 Owner/Operator /lax; <br />"- S-0,16lGiUS Check all appropriate services provided: kid-avat iajobe") 0.fcovymitts-v4 <br />ErVVastewater disposal lir3-compartment sinft4164( DlectricaI hook-ups <br />CVSolid waste disposal D Food preparation GrToilet and handwashing <br />QiHot & Cold water for cleaning 0 Store refrigerated food Er Potable water <br /> <br />Lo Store dry food/supplies i Crovernight parking YVehicle wash <br />i, Ark I rh.5 CrV7; , 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 <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in )-(2111.0(K-.) 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 /> <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd