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revocation and penalties <br />Signature <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />C, <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 Rxn(jek: Sy)/ R\fAcAdc__ Lic. Plate # <br />Owner/Operator Name PN-11 ret-p Gour-apt <br />Business Mailing Address (A) CAA L-n <br />City 1---0 State C-1-Zip 90-40 Bus. Ph.51 6 -14-1-1 Alt. Ph. )-OCI-S6re-SS.S7 <br />e4Oeco (a17--Qt , hereby state that the above information is current, true and correct to <br />the est o 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 />Date /6/vi/a; <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name -OCI<O),) CO)(COVIc-VTC4c7t) FA# <br />Address \AP !tort (.4.bc,, Bus. Phone Zdi - 6V8--S-CtS-5- <br />City ``A0C-0p Zip °I-SZO Z. Owner/Operator cR (t(P, \13i4kke?-1 <br />Check all appropriate services provided: <br />Er Wastewater disposal Er 3-compartment sink .Electrical hook-ups <br />WSolid waste disposal jaTood preparation .ErToilet and handwashing <br />Er Hot & Cold water for cleaning CrStore refrigerated food P-Potable water <br />0 Store dry food/supplies 0 Overnight parking 0 Vehicle wash <br />`RztivQ. , 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 sAh oti th EHD immediately. <br />Signature Date lo (a4 ( e3 <br />3. To be 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 I F 209 464-0138 I www.sjgov.org/ehd