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SAN JOAQUIN <br /> 'iromr9ntal Health Department <br />—COUNTY -- <br />GreOtris (roe, <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 ?c,\ \-ce \C:U fc-a Lic. Plate # <br />Owner/Operator Name "c7c-a \-tyv v. 7c/d cl <br />Business Mailing Address Fi1F:013 cr-A v RA <br />City /9(ii) StateUl. Zip 753,3 -T Bus. Ph. Alt. Ph. <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 discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />Signature 4( /TLC" tr /p Date <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name c \c- N L) FA# <br />Address (-2?`4 ( LE; in'iii,,,( c",,J.-e Bus. Phone <br />City A-()(, Icl-ok Zip cr 5 Z,_-:5- wn_00perator 'V CA — <br />Check all appropriate services provided: <br />0 Wastewater disposal 0 3-compartment sink '\''q Electrical hook-ups <br />0 IV 4 <br />X m <br />-1 • C) n Solid waste disposal 0 Food preparation i7.74, Toilet and handwashing 0 E 0 Z — _ 71 Hot & Cold water for cleaning .EL'Store refrigerated food r2 Potable water <br />0 rn m <br />Q Store dry food/supplies t:k,Overnight parking D Vehicle wash > X 0 cc) > <br /> 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 t3) I 71 g is <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the cyl ' 7, <br />commissary owner shall notify the EHD immediately. <br />Signature _?-11' 4 " <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 />c),tz 0 5LA <br />Date