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SAN JOAQUIN <br />COUNTY <br />Greatness grows here. <br />OS-L-1 -1(PC2 <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 />.,-.---- <br />Lic. Plate # ‘C 6 il e‘7 Business NameTa.t c c MO-1.c."-i44' 16— JO,- <br />Owner/Operator Name ficAilt 7.: e...fte.,_ <br />Business Mailing Address 35 I c 5rb Iv <br />City StateCA Zip er2_t5- Bus. Ph. 245 61V6V12 Alt. Ph. <br />e (- <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name t-k- levN i-FA# <br />Address ik YvTh S Bus. Phone(2-O) 0 S' <br />City Joie_ re4-- Zip q 441- 0 Owner/Operator ,TO S-c— Vv"• r-t) <br />Check all appropriate services provided: <br />le/Vastewater disposal <br />ErSolid waste disposal <br />Ei Hot & Cold water for cleaning <br />IY-Store dry food/sup lies <br />c3-compartment sink <br />C3 Food preparation <br />Store refrigerated food <br />ErOvernight parking <br />'Electrical hook-ups <br />Ertoilet and handwashing <br />ErPotable water <br />IT-Vehicle wash <br /> <br />, hereby state that the information I have provided is current, true and <br />correct •1 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 />, hereby state that the above information is current, true and correct to <br />the best of my knowledg 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 I /6( 20 2-? <br />commissary ow er sh. • - - immediately. <br />.„. Date Signature <br />3. To be completed by the NV HEALTH jurisdiction outside of San Joaquin Co. <br />County. The above food facility meets the <br />commissary requiremen in California Health & Safety Code. The above checked services are available at the <br />above commissary. Pj e notify EHD if the s s of their operating permit changes. <br />Date o.d1 <br />1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />The commissary is located in <br /> <br />MliAdn <br /> <br />REHS Signature