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SAN)ffittOUIN ,k\ <br />-711U- —COUNTY- <br />0415:eleq- r- ...7rectness grows here_ <br />Pi2 O511-10 <br />Environmental Health Department <br />Fick- O02-13W <br />— <br />COMMISSARY COMMIS8ARY 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 />Business Name gctrct 47-)04-beA <br />Owner/Operator Name cctc vv) 6-t roL1 L <br />Business Mailing Address /003-7" <br />City Stoc-400 State C-'0 Zip etra-(9 Bus. Ph. 4,C,9 -./14711/5Alt. Ph. <br />f, V.er IAo d Pt-Lq , 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 and pe Itie <br />Signature Date /417 r (‘' gi <br />Lic. Plate # ty-p?7_. <br />Commissary Name Vick \\I (70 <br />Address Sq (2_ E a1/4xe <br />City Sitcic Zip q) 2 0 5. Owner/Operator <br />Check all appropriate services provided: <br />FA# <br />S7011-16::2 wt. cti re (1 <br />Bus. Phone 20q--- <br />ci Wastewater disposal <br /> <br />CI 3-compartment sink <br /> <br />ti-Electrical hook-ups <br />CI Solid waste disposal <br /> <br />O Food preparation 41-Toilet and handwashing <br />EL Hot & Cold water for cleaning o Store refrigerated food <br /> <br />O Potable water <br />Store dry food/supplies P. Overnight parking ▪ Vehicle wash <br />I, 5 ,1 +(A Vi ,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, tim 2 <br />commissary owner shall notify the EHD immediately. —1 <br />X <br />0 Iv m Z <br />GI <br /> g 0 <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 thf, rrs <br />above commissary. Please notify EHD if the status of their operating permit changes. 0 > <br />< m . E <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />Signature J. Date 3 <br /> <br />REHS Signature Date <br />NoS4o4jc1 S