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SANINJOAQUIN <br />—COUNTY— <br />Grcetness growl here. <br />Environmental Health Department <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 "I&C,,S LOS S Lic. Plate # <br />Owner/Operator Name WC-Inc 1-)e,f\,s <br />Business Mailing Address 30aCC_Q\ \)r <br />City tOkliVery5_ State() ip q5J Bus. Ph.g2CI-P5 -6gag\lt. Ph. <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. lithe 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 p;nalties. <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Cvevvvkli 4,c, bc- Cbge e <br />Address 32.16 ?".c.4' (-- Ard.e Bus. Phone (1-k 06)-771 -2-LLI <br />City S \-0 e- lc 4-11,,-‘ Zip GI ft orf- OwnoriOperator l•-A--0.-\.4 Sa,,,--; ,s,.." <br />Check all appropriate services provided: <br />0 Wastewater disposal jid 3-compartment sink F 'Electrical hook-ups <br />13 Solid waste disposal fie Food preparation pf Toilet and handwashing <br />pf Hot & Cold water for cleaning 0 Store refrigerated food je Potable water <br />0 Store dry food/supplies 0 Overnight parking a Vehicle wash <br />I. •/‘-‘,.,-L<- F:).-A r I-‘ , 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 s all notify the EHD immediately. <br />Signature Date '1 /"?.... t /2-b2- g <br />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 END lithe 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 <br />146,1-or YS - <br />Signature 441gerAe Date q ic;11q <br />FA#