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• p,OU/A, <br />4.? SANJOAQUIN <br />COUNTY 44S:e2r- \\.0 04N,r, Greatness grows here. <br />Environmental Health Department <br /> <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 />Owner/Operator Name V\.,k3( C(Icia 4e ( fere, kod-L 127_ <br />Business Name a CI cAUCINkk `4Q.,;t4Cilvt -RIM Lic. Plate # <br />Business Mailing Address V. 0 r-2,0 \0V C04) <br />City eVtcco State CA- Zip cisz.-54 Bus. Ph. 2,b9 -6, -ssa Alt. Ph. <br />I, 12‘.c1/4u G 40-4-revcs. 'Lk , 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 />revocation and penalties. <br />Signature <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name l'3" <-> FA# <br />Address -2- (a C C tiNv, Bus. Phone L(c-; <br /> <br />City L--C)6'‘ zip ti 0 Owner/Operator C"-'c• <br />Check all appropriate services provided: <br />`Ei Wastewater disposal --51 3-compartment sink <br /> 'El Electrical hook-ups <br />El Solid waste disposal --19 Food preparation Toilet and handwashing <br />Hot & Cold water for cleaning -----1::F-Store refrigerated food <br /> <br />13 Potable water <br />'Et Store dry food/supplies CI Overnight parking CI Vehicle wash <br />jy- I-1 vr\ c: , hereby state that the information I have provided is current, true and <br />correct to the best of h1y 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 ownef sha o the D immediately. <br />Signature 1-2-17-1 Date <br /> <br />To be completel 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 />RENS Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />fP°9-1 33.5g <br />Date t 2- 21- --2-4