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rUkar k(e)-k- <br />Bus. Phone a ock ct4,6— <br />FA# <br />SAN JOAQUIN <br />.0 —COUNTY . • <br />• <br />Environmental Health Department <br />Greatness 91-01'15 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 />1. To be completed by APPLICANT <br />Business Name <br /> <br />EL T mVo <br /> <br />Lic. Plate # Giegl ii <br /> <br />Owner/Operator Name JO e_ILk OpflQ <br />Business Mailing Address '32 r[ef <br />City 8ketcA00 Stateea Zip ets203 Bus. Ph. 20 -591: lqed Alt. Ph. <br />I„c)0 rc Wiretlb , hereby state that the above information is current, true and correct to <br />the best ()tiny 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 <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Address 5: <br />City C3'k-inC0011\ Cb Zip 7540) Owner/Operator %Ibk11 ?OtIC e._ <br />Check all appropriate services provided: <br />Wastewater disposal Ef 3-compartment sink 13 Electrical hook-ups <br />Solid waste disposal Ell Food preparation a Toilet and handwashing <br />Hot & Cold water for cleaning CI Store refrigerated food 0 Potable water <br />Sp.e ilry foodAupplies CI Overnight parking 0 Vehicle wash <br />I, iirt 00 YnnCe , 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 -Pckb i 0 (--c) a ce_ <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 />Commissary Name <br /> <br />Q,x Lc) <br /> <br />Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd .