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commissary owJ hail notify the,iO immediately <br />Signature Ddi rz/z)9-/z <br />SAN J3A <br />1.1 <br />IN <br /> <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Comp,'ere sections 1 and 2. tf your cornmrssary is öca red ourside of San Joaquen County also comp/ere section 3 <br />1. To be completed by APPLICANT <br />Business Name k<00\14G V..ockAs _,,4e---4--6145Lic Plate # <br />OwnerlOrperator Name <br /> --\--0,,Arv_ ic:/EAD- • 1'09C) <br />Business Mailing Address 2-j5 Otck- <br /> StateDpi Zip q° Bus Ph .2 oq -0-‘51.\ Aft. PhS <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 IEHD) requirements If the use of the <br />commissary is discontinued the permit holder must notify the END Failure to notify this office rr ay result in permit <br />revocation and penalties <br />49/Yati <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name T•::)c.K-roti c..c44.Kuu rr a44-1Et--):T <br />Address %10 14- at- o-P A.00 Bus Phone (o) ctael <br />City "bar oc-rot-i Zip cif; 2.02. Owner/Operator LEOWEL C..ALILLOCOPOLUSIDESk <br />Check all appropriate services provided: <br />tpLWastewater disposal <br />TA Solid waste disposal <br />10 Hot & Cold water for cleaning <br />lir Store dry food/supplies <br />3-compartment sink <br />TA-Food preparation <br />vi Store refrigerated food <br />0 Overnight parking <br />121 Electrical hook-ups <br />-Er Toilet ard handwashing <br />Potable water <br />0 Vehicle wash <br />I, ,i-goust- tie31-14-t...0 , 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 of cancelled, the <br />Signature Date <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 />!MS E Hazelton Avenue I Stockton, California 96205 209 468-3420 F 209 464-0 38 I vow. Sgov orgiehd