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SAN JOAQUIN <br />—COUNTY <br />Greatness grows here. <br />Environmental Health Department <br />.0113:er,. <br /> <br />COMMISSARY AGREEMENT <br />Mobile Food Facility. Caterer <br />Complete sections 1 and 2. If your commissaty is located outside of San Joaquin County also complete section 3. <br />To be completed by APPLICANT <br />Business Name Lts‘ Pist-T-goNp. Lic. Plate # 3235$615 <br />Owner/Operator Name NI IN Esuvlv - citozcips <br />Business Mailing Address (JO Lis g.E CC Is N <br />City g"I‘J g12—PSI\114tate_CAZip(1631.91 Bus. Ph(2.061)IM12.3iAlt. ph/201\5A --21pq <br />I, NI cN ESONIVEL , 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 />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name \)1\1 N (Anr-11\14 114JCP 01\44644c/7 <br />Address 1111 VNION T. Bus. Phone (20 61) 2-1 - 5 11/IP <br />City STD (K-IDN Zip °151,0 t, Owner/Operator 12—Ki IzENE T1 ftDO <br />Date OS 111-1 20211 <br />Check all appropriate services provided: " IN I\ S H 0 N L\J " <br />N*Wastewater disposal 0 3-compart 0 Electrical hook-ups <br />X Solid waste disposal 0 Food preparation <br />X Hot & Cold water for cleaning 0 Store refrigerated food <br />0 Store dry food/supplies 0 Overnight parking <br />I, \leSIY- -t& SO SO.- , 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 />commissary owner shall notif ediately. <br />Signature Date 06 ] 22 I 20211 <br />Toilet and handwashing <br />Potable water <br />Vehicle wash <br />3. To be complet d b 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 <br />PPOG