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SAN JOAQUIN Environmental Health Department --COUNTY - Gfecittns COMMISSARY AGREEMENT Mobile Food Facility Caterer Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. 1 To be completed by APPLICANT Business Name Owner/Operator Name /1 /4EMAINAt, SW/1/JP e Business Mailing Address 82 39 hanthetrd City STO C KtO"/ State C-/ Zip 9524 0 Bus. Ph.Z0qq5 54 Alt. Ph. illaaroniaci ku rtf , hereby state that the above information is current, true and correct to the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit revocation and penalties. Signature ,AVI kg To be completed by COMMISSARY OWNER/OPERATOR Commissary Name I <;_ Address i.3 kii I s . E i r-,- ,E-'P '‘A-Vc----- Bus. Phone '\ \AV-- L i \Act L.------ City C ;''-4) r ./<' -7- Zip /' rL (-% Q_S Owrier/Operator i71 13 ) 'N - Wastewater disposal Ei 3-compartment sink L Electrical hook-ups . rri z 0 D Solid waste disposal 0 Food preparation Toilet and handwashing 73 Hot & Cold water for cleaning 0 Store refrigerated food ,,„4 Potable water z 3 (--) m m 0 Store dry food/supplies 0 Overnight parking 71 Vehicle wash > X 0 hereby state that the information I have provided is current, true andui < rzif (0 > correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility18 RI 111: operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, tha,71 IC commissary owner shall notify the EHD immediately. Signature _- To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. The commissary is located in County. The above food facility meets the commissary requirements in California Health & Safety Code. The above checked services are available at the above commissary. Please notify EHD if the status of their operating permit changes. REHS Signature Date 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd Sum/Vy ICE CRel)n4 Lic. Plate # 8/V'1"7/70 Date FA# Check all appropriate services provided: Date