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Date 05)12.2 1202-11 <br />commissary owner shall notif ediately. <br />Signature <br />SAN JOAQUIN <br />—COUNTY--- <br />Greatness grows here. <br />Environmental Health Department <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 L Pt :p1sc112- N Lic. Plate # 32 5e 615 <br />Owner/Operator Name N Ni G\I Esa\) - 6-1tcCl ix <br />Business Mailing Address (s0 143 CC A L N <br />city?-1\15-gf\NLte_CA_zip4'16311)1 Bus. ph4061) 12.32Alt. phi/01\51A --hog <br />I, NI Ps NO EZ.VIVEL <br />Date us] lweid eLovi <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 91\110N UtTtr-IN4 114141 NCI COMilvt4sPkF- <br />Address 1111 S V NI ON ST Bus. Phone (2960 1'- 2,1 5t/ILp <br />City STD (K-rb N Zip et 510 ki) Owner/Operator 12-0c1 izENEr-lkD <br />Check all appropriate services provided: " W <br />\91,Wastewater disposal 0 3-compartFR <br />)(Solid waste disposal <br />Hot & Cold water for cleaning <br />Store dry food/supplies <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 disco inu d, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and p <br />Signature <br />0 " <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 />0,. 50g-6 , hereby state that the information I have provided is current, true and <br />correct o the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply with of this agreement, or if this agreement is modified or cancelled, the <br />3. To be complet d b he HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located i County. The above food facility meets the <br />commissary requirements in ifornia 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