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<br />SAN JOAQUIN <br /> <br />E nvironmental Health DePartment <br />__COuNTY — <br />COMMISSARY AGREEMENT <br />Mobile Food Facility • Cate-er <br />is /crated cutside ci San Joaquin County disc) compote Section 3 C e cmiloto seelons I and 2. If your cora7vssarY <br />- - -— — LtTpb ornpted by APPLIC_ANT <br />Business Name <br />Owner/operator Name A iciorN eLfoora c."Lic. Plate # Vi/X 7 <br />Business Mailing Address 10 0 VC) <br />CrtY___IDICACtOn State Ph. cit (LL- LI393Ait. Ph. Citb - <br />Anile _&3642, hereby state that the above information is current, true and coned to <br />the best of my knoe4edge and agree to utilize my aPProved commissary in accordance with California Healtri & <br />Safety Code, and San Joaquin county Environmental Health Department ([HD) requirements. It the use of the <br />cornmissany is dscontinued, the permit holder must notify the END. Failure to notify this office may result in permit <br />revocation and penalties. <br />Signature --->-)...CtrA \r-C, 7 V\ a C' Date //-- q• a - .dcl <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Namo e ( FA# <br />Ad d r oss S Bus. Phone N 9I /-)571 <br />City (e‘ ZiP.if)j710 Owner/Operator PIA) <br />Check 81 appropriate services provided: <br />pt Was:ewater disposal <br /> <br /> K Electrical hooc-ups 0 3-compartment sink <br /> <br />Sol.d waste disposal 0 Food preparation El'Toilet and hand...dashing <br />A Ho: & Cold water for cleaning 0 Store refrigerated food pe, Potable water <br />O Store dry food/supplies 0 Overnight parking gr Vehicle wash <br />I. tilt tiez76 /17/b/a 4' P-Z , hereby state tnat the information I have provided is current, true and <br />correct to the best of my knowAge. 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 owner shal polity lhe c...H,D)rftwidialuly. <br />Datei2c <br />_ fn-__2.7 ,.._e <br />Signature / r--- <br />[q. To be completed _Oy the CTIEALTH jsdiction o <br />s <br />utside o Joaquin Co. 1 <br />The commissary is located In <br /> <br />t. ae-Guboverv4 checkedTh1 e s e <br />1.a__ <br />above <br />rvcefos ar <br />food <br /> <br />dfeaacivliable at thetyila <br />th meets e commissary requirements in California Health & Safe' i Code The <br />aoove commissary. Please notify EHD if the status of their 0Perating permit charges <br />REHS Signature <br />Date <br />858 E. Hazellon Avenue Stockton, California 95205 I T 209 4 68-3420 F 209 464-C138 I w'tWv.Sjig ov .or g /eh" 1 <br />FR osLIS01-5