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pr1) .)C-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 completed by APPLICANT <br />Business Name 0/;) e <br />Owner/Operator Name 5"-evre.__ kilmicret <br />Business Mailing Address o%, <br />City j r a L.->k,. StateClq-Zip 733 9 Bus. Ph.1,77 0; Alt. Ph. /Irk <br />I, 1 -7,/,6Y1— V/4/4-23 , 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 disrrtinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and pvf,ayie_s. ' <br />Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Lic. Plate <br />/ / Signature r s <br />Commissary Name -1-n4:61Weake FA# <br />Address 1.9,00 L.Lither"' Bus. Phone tiaS t-k4-r1 6---1110 <br />City 1—Wer rr`Or Zip Cti-k5S--) Owner/Operator reitEL4'e Slepro.L.C?:. <br />Check all appropriate services provided: <br />q 'Wastewater disposal <br />-14olid waste disposal <br />/Hot & Cold water for cleaning <br />Store dry food/supplies <br />3-compartment sink <br />L Food preparation <br />f. Store refrigerated food <br />Vtvemight parking <br />/Electrical hook-ups <br />Vroilet and handwashing <br />iiPotable water <br />Abide wash <br />I (,'Es* irvA A (.arv,02..e-> , 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 ownei shall ;9Aify the EHD immediately. <br />Signature ( Date I o) a /44144 <br />I 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co <br />The commissary is located in A UN NA 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 <br /> <br />„ <br /> <br />Date - - 2-02_,Lt <br /> <br />1868E,',1-iazzAon Avenue I Stockton, Caiifornia 052061 209 468-3420 F 209 464-0138 www,sip,c,tv.orgiehd