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-peosqgqz(-1 <br />SANJOAQUIN <br />• <br />lnvironmental Health Depart r <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 compteted by APPLICANT <br />Business Name_ 14 //i2p/f). )-1-- e Lic. Plate # LTIVI <br />Owner/Operator Name 57-eve__ <br />Business Mailing Address a%, - <br />City / a StateCA-Zip ?5-3.79—Bus. Ph. 710 cig7-9/ Sig- Alt. Ph. <br />I„ 7)//1 /4-2 , 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. lithe use of the <br />commissary is disc9i%tinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and p <br />Signature V Date ZIL,Cg, A1021 <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name -1-n-kedr'elieake 54•Ort/Cf_ FA# --- <br />Address 19,00 .Suither cF Bus. Phone gas --AA-kri <br />afi-k.-1 Owner/Operator Eitsi+e SidDrcv.,4C. City 1-% \ter inor e. Zip <br />Check all appropriate services provided: <br />Wastewater disposal 3-compartment sink <br />41olid waste disposal <br /> <br />O Food preparation <br />Hot & Cold water for cleaning O Store refrigerated food <br />Store dry food/supplies N•15vemight parking <br />I, e..!‘"C" kEs-k INCA A Ci , 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 yith the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owntshaIlpJtify the EHD immediately. <br />Signature CULLIV) <br />IT-To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in _A \_.-A INA -Z-A:2)Pit 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 -0 I - .2-0234, <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 209 4684420 I F 209 464-0138 I www.sjgov.orgiehd <br />LAlectrical hook-ups <br />EVroilet and handwashing <br />R‘table water <br />ge4.ehide wash <br />Date