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14. o s L-1 m <br /> <br />SAN ,JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY -- <br />1 1 ! I r re. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility 0 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 t\A Cz-1 0 1, Lic. Plate # <br />Owner/Operator Name ItIVNI- /1 I f ) 11() <br />Business Mailing Address (1 (..,,SG C <br />City State CA Zip C6-3"-/ Bus. Ph. .2_tq- 2-1 `lc( 7f-i Alt. Ph. <br />I. //1 (--6) f)er ( • , 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 discontinue 51/, the permit holder must notify -the EHD. Failure to notify this office may result in permit <br />revocation and penaltie/... - <br />Signature <br />To be jcOmpleitild--by COMMISSARY OWNER/OPERATOR <br />4.4 PIA 7,14 FA# oo ,2 7 493 <br /> <br />d_ A smi Fclt_ Bus. Phone ,20, - 7/ 2..._— iqe 24, <br />Zip 9$ ;30 Owner/Operator 51—R.V.,— ThAlltifi-C4 14144 Ilnop <br />Check all appropriate services provided: <br /> <br />Wastewater disposal 0 3-compartment sink a(Electrical hook-ups <br />Ise Solid waste disposal 0 Food preparation e "Toilet and handwashing <br />0 Hot & Cold water for cleaning 0 Store refrigerated food Tip/Potable water <br />0 Store dry food/supplies SlOvernight parking ITiK/ehicle wash <br />L <br />4.14 , hereby state that the information I have provided is current, true and <br />i 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 own hall no ga e EHD immediately. <br />Signature aV _ Date <br /> <br />To b 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 />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 F 209 464-0138 www.sjgov.org/ehd <br />A4P4't ) d dre_ss Centmic-) R(id )9 q c11 ), CóYrt <br />v <br />Date / 2//CPc 2 -73 <br />Commissary Name <br />Address i (0 a o <br />LA7 <br />, .54-;"_