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t„.0.oiN cs•. <br />. <br />.‘ \ <br />r <br />SAN •JOAQUIN <br />COUNTY <br />1'Ieyy)(7/ PR as-3 63- co <br />Environmental Health Department <br />Greatness grows here. <br /> <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 \kvt k/6"(\z- <br />Owner/Operator Name SHAk...CA_ \r•rvf,if-Q.-tilx) <br />Busines wailing Address \06 --Vt" <br />Lic. Plate /r2):7 PrZ) Ai <br />Ci ieRN/ Statec.Lk Zip Bus. Bus. Phbr4g25 -90(:19 Alt. Ph. <br />(L)\. V VI-CALL-I, , 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 enalties. <br />41' A <br /> <br />Date Lk t Signatur <br /> <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name A I '-Cyr 144 / <br />Address 2(4L11) ez, L.4...,"‘„*;) Bus. Phone 217, /v/-e) <br />City s-i--„,7,4 zip 5 -24,-1 Owner/Operator 12-()buv <br />Check all appropriate services provided: <br />-11 Wastewater disposal <br />iq Solid waste disposal <br />&Hot & Cold water for cleaning <br />0 Store dry food/supplies <br />11(3-compartment sink <br />Food preparation <br />gi Store refrigerated food <br />Overnight parking <br />L' Electrical hook-ups <br />qt Toilet and handwashing <br />ei Potable water <br />(,0 Vehicle wash <br />, 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 t - 1011110ediately. <br />' <br />Signature <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 />A_Jj Svpil 9 FA# <br />TP-i-irt- <br />Date 1 (10//z