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SAN JOAQUIN <br />" COUNTY— . „- <br />Environmental Health Department <br />Greatness grows here. _ <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 />To be completed by APPLICANT <br />Business Name <br />Owner/Operator Name <br />Business Mailing Address \\(-)i- k0 <br />City CN3,\ State N Zip? Bus. Bus. P1-€_:ahck) (LO Alt. Alt. Ph. <br />I, 'DCT T-5_, .\C''\ .hereby state that the above information is current, true and correct to <br />the best of my knowledge and_agfeeltratifiz my approved commissary in accordance with California Health & <br />Safety Code, and San_J-cra4u- in County Environ ental Health Department (EHD) requirements. If the use of the <br />commissgry-is-diSeorcintinued, the per- it hold ust notify the EHD. Failure to notify this office may result in permit <br />reyoca-o-n and-Penalties <br />Date '7 G - <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 7 ...44464er.c:-r/ A ?It-A_ FM <br />Address 6 2,./ ,7 6,-L-40-t-(fri le- -:-.)-\-- Bus. Phone (-7-cM) 9-1-i 933% <br />City Z.-( Zip cri5z 762 Owner/Operator kicii-ei AP c.--7-e--e:-4.-- '-- //,%4e-eY ....10--.4 -i-- <br />Che2 k all appropriate services provided: 0 <br />4Z4 <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 the EHD immediately. <br />Signature <br /> <br />Date 3- 4-- :24/ <br /> <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 T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />P‹ <br />Lic. Plate # W X (c) :)0.1(p <br />VV}.stewater disposal <br />trSo - waste disposal ca7ltd <br />Hot & Cold water for cleaning <br />V"tore dry food/supplies <br />3-compartment sink <br /> ri Electrical hook-ups <br />F,od preparation p(fOilet and handwashing <br />r 'ere refrigerated food Vi'9abIe water <br />"overnight parking <br />'Vehicle wash <br />, hereby state that the information I have provided is current, true and