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FinSIA (nt-I3 <br />SAN JOAQUIN <br /> Environmental Health Department <br />COUNTY— <br />Greatness 9rows herr-, <br />COMMISSARY AGREEMENT <br />Mobile Food Facility t) 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 14 ; rAck IS Lic. Plate # 3 12 03 2(9 <br />Owner/Operator Name 0/1 )1\ I S n u {c,A <br />Business Mailing Address 65 I-7ci c e tcf JCRA , v • <br />City ."L k Ckk State C RZip Ts--)8 Bus. Ph. Alt. Ph. iv) E75- V6 56 <br />I, C v XIC.3 10 'be_ir CA , 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 e alties. <br />Signature <br />To be.comPleted by C MMISSARY OWNER/OPERATOR <br />Commissary Name LCA. Copief c d. Co( 9 - FA# <br />Bus. Phone - 4-1(2q - 3" -70 Address c)—et DO E , a on <br />City Skis (X-k CPC-N Zip q-s20s- Owner/Operator G1a i2 "( ki p " 1 <br />Check all all appropriate services provided: <br />Wastewater disposal <br /> D3-compartment sink <br />Solid waste disposal <br /> <br />CH Food preparation <br />Cr---Hot & Cold water for cleaning <br /> O Store refrigerated food <br />0 Store dry food/supplies <br /> Overnight parking <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 />C,( PDG•xl...s?--rx S , hereby state that the information I have provided is current, true and <br />commissary owner shall,tify the END immediately. <br />Signature <br />o 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 />Date - 2cr2q <br />IkElectrical hook-ups <br />4it_Toilet and handwashing <br />dELPotable water <br />d3:Vehicle wash <br />Date - 3 6 - o2-c-I