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SANHAQUIN <br />--COU NTY----- <br />Greotness ()cows <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 />.PP.LICANT <br />Business Name A-- 1/1 er l' Co( 0 Cy 1 --f-- <br />Owner/Operator Name R_ i OA G‘ v a 1,0 ov ci v i) ryi <br />Business Mailing Address 2 I 3 GI ( CA YA GI ca vi.c\ L 1-.3 L V D <br />City %) (..-kk-01-1 State 0, R Zip 9 2i 75 Bus. Ph. Alt. Ph. (''///0) F-5c1- 246 <br />1,g-c4aPd . 29- 06 o cicu /4 12-- <br />Date <br /> 11 - //- 202-,b <br /> <br />,.0.0ted MISSARY OWNER/OPERATOR <br /> <br />Commissary Name 7k 40-19 4--, -641z ( -- <br />Address OL/•7 u)Bus. Phone ,,& eji - 2-/o' zi - ;.i.-- 9 0 <br />City (Y Zip 675 ,(').3-- Owner/Operator, A, 'N ' l(?/Ziliiii. <br />Check all appropriate services provided: <br />isj Wastewater disposal <br /> <br />3-compartment sink <br /> <br />O Electrical hook-ups <br />Solid waste disposal <br /> <br />O Food preparation <br /> O Toilet and handwashing <br />a Hot & Cold water for cleaning <br /> O Store refrigerated food <br /> <br />O Potable water <br />O Store dry food/supplies <br /> el Overnight parking <br /> O Vehicle wash <br />a flUS , hereby state that the information I have provided is current, true and <br />correcf 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 sh II notify the EHD immediately. <br />Signature <br /> <br />Date i —Ii —20 2 3 <br /> <br />41,.* <br />he ENV HEALTH jurisdiction outside of San JoaquintO' <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 I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />Lic. Plate # (NV El°1 <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. 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 enalties. <br />Signature 9e,ore--e-f.e-7'71--fr- <br />FA#