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REHS Signature _ Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I 1 209 468-3420 I F 209 464-0138 <br />.,..„....,, <br />/°T:. SAN:JOAQUIN <br />—COUNTY— <br />\c'1t ,,A1 Greatness grows here. <br />Environmental Health Department <br />PRaS-3 001f <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 I-6,4 cy-yc <br />Owner/Operator Name Macrertn- M <br />Business Mailing Address 3 s orb frve-- <br />citycf-ock./v n State614- Zip eta/3' Bus. Ph.9-0 q 6119...6/0 Ait. Ph. <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 penalties. <br />SignatureAlcortro..... Mtrre.-nexA__ <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name '00.'N 962:_c-t• FA# <br />Address 2-\ Lk) ,s!):11-- <br />City t (.50‘. a, (4-- zip c1561-1-0 <br />Check all appropriate services provided:, <br />astewater disposal W3-compartment sink <br />IV/ olid waste disposal r6od preparation <br />Hot & Cold water for cleaning giStare refrigerated food <br />Store dry food/supe.119 Overnight parking <br />I, r...—c--P- -----.. , 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 />the EHD immediately. <br />Lic. Plate # te6 4 3 0 <br />Date ( 2— ).1-- <br />Bus. Phone <br />Owner/Operator <br />2_0cA <br />Cilectrical hook-ups <br />I:1 -Toilet and handwashing <br />rito able water <br />Vehicle wash <br />commis ry o <br />Signatur Date 11.—`21-- <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in 7114.(M> e) 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 />/2zrz.1 <br />www.sjgov.org/ehd