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61t4 o" <br />------COUNTY <br /> <br />0 5uf <br />Environmental Health Department <br /> <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 />Owner/Operator Name/0 lAdIN V)1Z-e1(__ <br />Business Mailing Address )-3 3 ( f. Ow S V11, <br />statal Zip K-22OB us . Ph.,20 570 ' 57 UTAlt. Ph. <br />, hereby state that the above information is current, true and correct to <br />gree to utilize my approved commissary in accordance with California Health & <br />County Environmental Health Department (EHD) requirements. If the use of the <br />permit holder must notify the EHD. Failure to notify this officp may result in permit <br />3 <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name itef-e.au_ FA# <br />Bus. Phone (Zd 61) — <br />Zip 5 Z-Y d Owner/Operator Pcpoff're, <br />Check all appropriate services provided: <br />trastewater disposal, reC-compartment sink <br />itIS---olid waste disposal 14 Food preparation <br />_,._---- <br />12/1-1/—ot & Cold water for cleaning Li-- Store refrigerated food <br />EI,it'ore dry food/supplies 0'6;ernight parking <br />c1/61ectrical hook-ups <br />grfoilet and handwashing <br />gl'OOtable water <br />hicle wash <br />Z+C-Cit-L— , 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 /> <br />Signature <br />S. To be completed by the ENV HEALTH jurisdiction outiide 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 />Business Name coot 1Lew4,70 ja,e&r-, Lic. Plate # ( <br />City <br />1, it <br />the best of my knowledge and <br />Safety Code, and San Joa <br />commissary is discont. <br />revocation an pena <br />Signature j • Date <br />Address 6 2) <br />City 1-0D <br />pate - 3 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I 1 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd