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S3090, <br />SANAAQUIN <br /> <br />Environmental Health Department <br />NTY----- <br />Greatness vows here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility 8 Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />To be compregaWAPPLICANT <br />Business Name N C . c MmENSE Lic. Plate # P1 7D IK5 <br />Owner/Operator Name I\ NA 1 12 () 12-D D P-1 6-1 UL <br />Business Mailing Address 11'i 51 S SAN ,)0 I\M1 N -f-- <br />city STDCKYDN state (Pr zipqS 20 (Aus. ph( 201)1.22_3 (9(Illt. Ph. <br />I, RPci\A \V-- ) r-ODPICWE2._. <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 aaenalties. <br /> <br />Date OH I ta n <br /> <br />am)Po 4e 7. <br /> <br />Signature <br /> <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Electrical hook-ups <br />)6 Toilet and handwashing <br />Hot & Cold water for cleaning FicStore refrigerated food id Potable water <br />Storlrfy pod3supplies Overnight parking .1151_ Vehicle wash <br />I, U 1 fl\IE 11 o 6, hereby state that the information I have provided is current, true and <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 o er shall notify EHD immediately. <br />Signature kOlOkiUY\Q c.) <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 />' • <br />RENS Signature Date <br />1868 E. Hazelton Avenue Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />, hereby state that the above information is current, true and correct to <br />UNW CATV-INIC-1 TYUCk-1 NCI FA# Commissary Name <br />Bus. Phone (v)(1) 2my sint Address n S• UN1ONST <br />City SID C KT-0 NI Zip gc2_ b (40 Owner/Operator r--0S) /2- EW F )2froo <br />Check all appropnate services provided: Mi N CIM1 <br />Wastewater disposal )6 3-compartment sink <br />Solid waste disposal Food preparation <br />Date I b2- 2 0 29