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SAN JOAQUIN <br />- COUNTY <br />PDS3 t 450 <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility 4 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 Lic. Plate # 14e8/ 1 <br />Owner/Operator Name PICA-e14C.2 <br />Business Mailing Address /06 S• 5 1— <br />citycAlr\--eltraL4 StatECZipct S-36,3 Bus. Ph.91/5 96? Alt. Ph. <br />I, 59/4 r0.. 0 j":2 up , 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 />Signatur <br /> <br />Date 2 <br /> <br />Commissary Name AZ-ie <br />Address 6,20 5 SetCra.,i4A ia Bus. Phone (a01) -zzy — g-3st/ <br />City O/)i Zip 5Z'/c) Owner/Operator AVaiho <br />Check all appropriate services provided: <br />ED/Wastewater disposal [0r-3-compartment sink <br />OVSolid waste disposal 0 Food preparation <br />avHot & Cold water for cleaning 0 Store refrigerated food <br />0 Store dry food/supplies 0 Overnight parking <br /> <br />AZ_-1- , 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 shall notify the EHD immediately. <br /> <br />Signature Date <br /> - 2 y <br />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 <br />FA# <br />0 Electrical hook-ups <br />grfoilet and handwashing <br />UkKtable water <br />D</ehicle wash