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SAN JOAQUIN <br />--COUNTY <br />Greatness grows here. <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 />To be completed by APPLICANT <br />Business Name jI ,50,/9/050 <br /> <br />Lic. Plate # zzis GI 37 <br /> <br />Owner/Operator Name F rde, _car, ,no <br />Business Mailing Address Si c" 1* 41642 Se t <br />City .51ochil Statee.4 Zip q5?..05— Bus. Ph. 20749 Z- Yqq1 Alt. Ph. <br />1, kA 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 gl penalties. <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Cc' ii R)cru'", et,,, Lc 1 -, c),../41.1_ FA# <br />Address 2 q qu c-,. kcyor )-- Ctilti Bus. Phone ZE, CI - '---k/ — / 4 <br />City 00k }-0,A Zip Ci 3---zp q Owner/Operator 5-1- <br />Check all appropriate services provided: <br />Eg' Wastewater disposal <br /> El 3-compartment sink <br /> <br />RI Electrical hook-ups <br />ItKSolid waste disposal <br /> <br />Food preparation <br /> Ei Toilet and handwashing <br />Cr Hot & Cold water for cleaning <br /> <br />41 Store refrigerated food <br /> at Potable water <br />Store dry food/supplies <br /> rx Overnight parking . Q Vehicle wash <br />tot c.$ , hereby state that the information I have provided is current, true and <br />correct to the est 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 />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 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />17R05117L1t,ILI <br />Signature kt k•A (v./ -A 210 Date OH 7- Z_(/ <br />Date