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-Th-te.;( )0)\p‘e irc41(1 <br />- tukt 1 14 <br />Business Name <br />Owner/Operator Name <br />Lic. Plate # <br />SAN JOAQUIN <br /> <br />Environmental Health Department <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 Mailing Address <br /> <br />10 A .,LfVe1 <br /> <br />City 1/4,0\111ctiivAStateCC1 Zip ‘-:6---1-6-.2..,Bus. Ph. -C-1 1) :7-i, Ph <br />N (A)b?_, kA1/6414.1 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 HD. Failure to notify this office may result in permit <br />revocation and penalties. <br />tUk1,1&6 (6 <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Ffr,# <br />Address tO i\JC.IA) Bus:Phone <br />City k IL)) 4ric,, ') Zip (--/ 2---C-2L. Owner/Operator N C';:l. _ 6t,,-,Lio,v e,/,/. <br />Check all appropriate services provided: <br />(NANastewater disposal 7S)3-compartment sink XElectrical hook-ups <br />ppsolid waste disposal Food preparation jg: ' Toilet and handwashing <br />Hot & Cold water for cleaning )J Store refrigerated food , ?Potable water <br />I, Store d food/pupties <br /> <br />. Overnight parking ISLVehicle wash e <br />‘ \ U412- , L- it ivj e 1 , hereby state that the information I have provided is current, true and <br />correct to the best of my knowledge, and eets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply with the conditions of this agreem nt, or if this agreement is modified or cancelled, the <br />commissary owner shall notify the EH mediately <br />Signature Date 9 1964 <br /> <br />To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in C6t,kWeA;15 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 />Z/A.0 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />Signature Date / ( /2-61 <br /> <br />Commissary Name coiatuort rcx1 j <br />REHS Signature Date <br />PR0sLiViv-i