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Wastewater disposal disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br />0 Store dry food/supplies <br />121 3-compartment sink <br />Food preparation <br />Store refrigerated food <br />Overnight parking <br />SANJOAQUIN <br />—COUNTY <br />Greatness grows hero <br />Environmental Health Department <br />Plz osLigst-H <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 in i A Ca-lc / 00S <br />Owner/Operator Name ic-OrSv -1-1ere,9e iJ <br />3 fpfd 4,w,vcia PL w <br />City oh Q. Statethip_91C43us. Ph. P.011/P -70 Alt. Ph. <br />I, e rPe4t2 ;43 <br />Signature Date <br /> <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name (1-V-7,ILCIQi Z 6,//a <br />Lic. Plate # L -3y0// <br />Business Mailing Address <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 (EHD) requirements. If the use of the <br />commissary is discontinue , the permit holier must notify the EHD. Failure to notify this office may result in permit <br />revocation • • •enalties <br />FA# <br />Address <br />City di Zip 9f1-y Owner/Operator <br />Check all appropriate services provided: <br />Bus. Phone ?O9' 3-/Y <br />eid <br />tKElectrical hook-ups <br />FToilet and handwashing <br />)a--Potable water <br />pr Vehicle wash <br />I,Ale , hereby state that the information I have provided is current, true and <br />correct to the bes 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 E im / . ly. / <br />3. To be completed by the ENV_ EALTH 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 />RENS Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />Signature Date- <br /> P-17-23