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Address 2-1 (e., C tr\SJI-- ol(s <br />Bus. Phone <br />City <br />-2_001 (c> <br />C\iNer\- Zip /61-Lk 0 Owner/Operator <br />SAN JOAQUIN <br />---COUNTY <br />iFosA"' <br /> Greatn:ps. 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 Name cj Clekocak;XC&w Pn Lic. Plate # <br />Owner/Operator Name (s( qe ( /ere, kod-Lk).az. <br />Business Mailing Address V. O. r",0y, <br />City \, e_40 State (A Zip cisz_34 Bus. Ph. 1b9-6,63--At Alt. Ph. <br />the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br />I, ?c\ol. G 4errevN A , hereby state that the above information is current, true and correct to <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 />revocation and penalties. <br />Signature <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name (---k UNON-k FA# <br />Date t2-224 <br />Check all appropriate services provided: <br />\isi Wastewater disposal la 3-compartment sink <br />O Solid waste disposal --'13 Food preparation <br />Hot & Cold water for cleaning -Store refrigerated food <br />--13 Store dry food/supplies 0 Overnight parking <br />I, --""J•10-h C , hereby state that the information I have provided is current, true and <br />correct to the best of Hy 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 ()writ sha 0_1.5 the . immediately. <br />Grv <br />3. 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 I Stockton, California 95205 I 1 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />Electrical hook-ups <br />Toilet and handwashing <br />13 Potable water <br />0 Vehicle wash <br />Signature <br />"2-17-1174i' Date