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,-0, • SAN ,JOAQUIN <br />6i10 <br />\ • AO, <br />c.44Sx-er., , <br />01;04' Greatness grows here. <br />commissary vier shall n if the <br />Signature <br />3. To be'completed by the EN <br />Date <br />(o) ,g— -5-3g (JAW <br />H jurisdiction outside of San Joaquin Co. <br />ately. <br />Environmental Health Department <br />S'k VI DO (c2_ <br />NO P(2-0 .5-03 <br />FAT OoKS1 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 />1. To be completed by APPLICANT <br />P()TROA)I(> <br />Owner/Operator Name Nanq G5C70/VC/ <br />Business Mailing Address 60(/3 e6ecra L 0 <br />City gUe1i)cinj5 State CA Zip 95367 Bus. Ph.M?.998 1232 Alt. Ph. 'O9 5C8 1691 <br />P c0C\I 5o1c))() e 1 , 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 alti <br />Business Name (#C1 Lic. Plate # 31. 35-g (33 <br />Signature .4 04 C <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name A a frit 96AT Atop adi 681-F 5ioaA66-F Att <br />Address WO PCd4€600 VG! Bus. Phone &Coq 5349 5103 <br />City geli)cor &TIP) Zip cA foe Owner/Operator QZ'on ClarK <br />Check all appropriate services provided: <br />Date <br />Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br />Store dry food/su plies <br />I, Plavlitoi <br />3-compartment sink <br />Food preparation <br />Store refrigerated food <br />Overnight parking <br />Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />Vehicle wash <br />, hereby state that the information I have provided is current, true and <br />correct to the best of my krQvledge, 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 />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 l www.sjgov.org/ehd