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<br />SAN JOAQUIN Environmental Health Department <br />—COUNTY -- <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 />Lic. Plate # <br />Business Mailink Address <br />City S -l-OCk Cps-/Stateat Zip qs2011 Bus. Ph.,),0(11 6031/08 Alt. Ph. <br />I, (:,1-; SI,c4,4 I. .01- , 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 pen Iti <br />Signature <br />4. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name S :tv pi 10L FA# <br />Address 3O 0,Ura Bus. Phone ?0.1 Li <br />City ---)11-0a(kit,/ Zip Cg.),) -4— Owner/Operator --Cf.lcir\ \&ifri3/)- <br />Check all appropriate services provided: <br />1 To be completed. by APPLICANT <br />Business Name L-\\cN LG.iter DJ) <br />Owner/Operator Name C\f\r'3 dL ø Ki Lp,t, <br />'I wc-ed,c) ow/ <br />Date <br /> <br />..._s Wastewater disposal <br />olid waste disposal <br />81 Hot & Cold water for cleaning <br />4 Store dry food/supplies <br />)kk 3-compartment sink <br />k Food preparation <br />Store refrigerated food <br />Overnight parking <br />iv Electrical hook-ups <br />Toilet and handwashing <br />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 wr e all notify the EHD immediately. <br />Signature Date Oil VA <br />3. To 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 <br />tt <br />111 ' <br />1868 E. Hazelt.cr Avenue I Stockton, t'aliftrOga 9.5205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />8Wio <br />Date