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SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <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 />a To be completed by APPLICANT <br />Business Namely) poo R IA/DIAN' CU f C Lic. Plate # <br />Owner/Operator Name /<::1-Miq k c 9\16 <br />Business Mailing Address 6"?-g if 1J I c c - Lve ;I <br />Citycii—n C-4451,-1- State (719- Zip c/Sr%.( Bus. Ph. A O(1,-,L15-11 Z 11 Alt. Ph. o r 1/05' .V57 <br />I,/4k-vvvii-1„..\ \ S f.ifq , hereby state that the above information is current, true and correct to <br />the best of my fthowledge 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 andenalties. " C <br />Signature ovvv1C 9-,CN Date <br />2.To be ..by MIN/It$:$41R,L.:()):4INF F.31.0 P E RA T 0 R <br />Commissary Name eic\\\\\\+1'\c-, 't1 /4-e (Tr( FA# <br />Address C07.0 .rt-cx\i,) MC, -I-- Bus. Phone 2J366 2 <br />City LC.6\ • Zip qc 7.:Lq.), Owner/Operator • \f) \f-x\cVn OC:\nrci (Neiva, (2-a( t 01 <br />Check all appropriate services provided: <br />/3 Wastewater disposal <br />11. Solid waste disposal <br />i:LHot & Cold water for cleaning <br />o Store dry food/supplies <br />91S1-\--eCei , hereby state that the information I have provided is current, true and „ <br />correct to the best of my- nowledge, 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 />3-compartment sink <br />13 Food preparation <br />O Store refrigerated food <br />Di Overnight parking <br />ta Electrical hook-ups <br />CV Toilet and handwashing <br />la Potable water <br />D. Vehicle wash <br />commissary owner shall notify the EHD immediately. <br />Signature /7 <br />Date <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.org/ehd <br />Pk0sti qm--4-‘71