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Tr. <br />t=t glAne"T, <br />Gr E'Ot c'S:1-• 91.-Pkre$ <br />SANdOAQUIN <br />COUNTY <br />Frt CM) tt <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 />.1. To be coMpl*ed by.AMICANT . <br />Business Name 6 L-L-IE CAKKe5 <br />Owner/Operator Name KYND A L- HAM- t-f <br />Lic. Plate # <br /> <br />Business Mailing Address 3'3• 6-- A-MiN ST <br /> 'S?-e. -721 <br />City S1OCX-10/`1 State CA Zip qS207- Bus. Ph. 20.? 6.3‘7 7033 Alt. Ph. .209 936 g6o/ <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 discontinue , the permit holder mu t notify the EHD. Failure to notify this office may result in permit <br />revocation nd penalties <br />Signature <br />2.7To be cMMiMKRTYI5Wfi'MOPERATOR <br />Commissary Name V. V 1-0 C-0111-4E.W1 k.k.cdrt -:;),) FA# <br />Address , Bus. Phone 9 - (D -c <br />K,,f/ Kot64 MA,./1.6to <br />Date 3/15-12 02-4 <br />City 4.-.11)0k7-::)-) Zip A Owner/Operator riko <br />Check all appropriate services provided: <br />Jr Wastewater disposal <br />3-compartment sink <br /> <br />Electrical hook-ups <br />Solid waste disposal - Food preparation Toilet and handwashing <br />2'Hot & Cold water for cleaning Store refrigerated food <br /> <br />'Potable water <br />Store dry food/supplies Overnight parking r.7 Vehicle wash <br />I, V:r\-\—g-J c.:S2AA/\_91A" , 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 <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner skall notify the EHD immediately. <br />Signature Date / i r <br />A3TojorOccgrepleteddwah ENV outsid:44WW4 hi 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! Stockton, California 95205 I 7 209 468-3420 I i7 209 464-0138 I www.sjoov.ora/ehd