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SANAAQUIN Environmental Health Department —COUNTY— Greatness grows here. COMMISSARY AGREEMENT Mobile Food Facility o Caterer Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. Date 1)42042/ 1. To be completed by APPLICANT Business Name n RikA. e fie U it ('vCic-m I Lic. Plate # 3k.k; q Owner/Operator Name e LL 31:)-) P CS1Pr Business Mailing Address D `r C City 51O CiCles A) state CA- Zip CirC/ Bus. Ph. 24 - 6 irS- -1(119 Alt. Ph. I, e A FA C jAttu 6-- Pk ( STA- , 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 To be completed by COMMISSARY OWNER/OPERATOR Commissary Name U fJiC, ik) etcrEe,Axi leucc Address I 1 1 5 U i0 S 1 Bus. Phone 20(:)- City S1 MCTO 4..) Zip CiSoi 0 (,./ Owner/Operator ZOS j Ie tAJ1 —fife/400 Check all appropriate services provided: ft Wastewater disposal 0 3-compartment sink Electrical hook-ups 115 Solid waste disposal 1:1 Food preparation X) Toilet and handwashing Hot & Cold water for cleaning D Store refrigerated food 24.:1 Potable water st re dry food/sup lies 13 Overnight parking !SioVehicle wash esi F-ok. S 1i , hereby state that the information I have provided is current, true and correcL to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the commissary owner shal notify th D immediately. kVa/cf Signature Date To b 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. .. • RENS Signature Date 1868 E. Hazelton Avenue! Stockton, California 95205 f T 209 468-34201 F 209 464-0138 I vvww.sjgov.orgiehd ?Is7052c)11-1