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1'1)c Piedxy)Q/ PR as--3 "7- 5— <br />. "O <br />• <br />r SAN JOAOUIN I, COUNTY <br />Greatness grows here. <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 />To be completed by APPLICANT <br />Business Nam <br />Owner/Operator Name jr11\kkik_ \N\cf)Y,Q.Ant--) <br />Busines ailing Address ko 6 <br />Ci )661/1 Statecx.k ZipctirX7-5-3 Bus. Phb4gci5=W--").9 Alt. Ph. <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 discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />) 4 LA.. <br />revocation and enalties. <br />Signatur /1P Date <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Cel FA# <br />Address 2 Li Lto S.4-4 urA- LA_,K...=) Bus. Phone 14-?, /- <br />City S4v (.461t-tyl Zip 45--)2C-i Owner/Operator ``-i2--e-c <br />Check all appropriate services provided: <br />-fp Wastewater disposal <br /> E'3-compartment sink <br /> dr Electrical hook-ups <br />iq Solid waste disposal <br />&Hot & Cold water for cleaning <br /> <br />14 Store refrigerated food <br /> <br />I Potable water <br />Food preparation <br /> 41) Toilet and handwashing <br />Overnight parking <br /> OM Vehicle wash IZ( Store dry food/supplies <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 />I, `p_cle , hereby state that the information I have provided is current, true and <br />commissary owner shall notify t ediately. <br />Date 4somob. <br />To be completed by the ENV HEALTH jurisdiction outside of San Joaquin 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 1 Stockton, California 95205j 1 209 468-3420 1 F 209 464-0138 I www.sjgov.org/ehd <br />v6k1c-cd-rrif cfno-cl Lic. Plate #3q <br />Signature (10//7.-