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SANdOAQUIN <br />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 />1. To be completed by APPLICANT <br />Business Name .11 n1cy)(2 Sck\o Or. Lic. Plate # 8 R 9385-3 <br />Owner/Operator Name D-e_, c\ni.ec„ fncAcAy-L9o4 - C <br />Business Mailing Address Li i 1 (4- eiv" ( 00 Yrk yva, <br />City IN(GLCX\ State Zip 45 311 Bus. Ph.0-0) 0,55-I 1 2,1 Alt. Ph. 1.-1-0`i 83 (1 -1 wpq <br />1, --)ei,ion 'rot vodriclai -0. , hereby state that the above information is current, true and correct to <br />the bet <br />a <br /> of my knowledge and ree 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 ermit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalti <br />Date 3.- Signature <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Lc,, 0 Urn -e,y' c t a ‘ FA# <br />Address 2.-c1 DO .--c-t.srk-• t-kCorCkt)-IL.3 ,'t.) Cl I Bus. Phone C2PG) Lib LI— '4c 76 <br />City c,ADat-ken Zip CI32S5 S Owner/Operator GI a. "C.-IA.4) 'w Ak2katA4 -V_ <br />Check all appropriate services provided: <br />rx Wastewater disposal i:1( 3-compartment sink tit Electrical hook-ups <br />IX Solid waste disposal 0 Food preparation X) Toilet and handwashing <br />gi Hot & Cold water for cleaning 0 Store refrigerated food n Potable water <br />0 Atore dry food/supplies ig Overnight parking IX Vehicle wash <br />I, ( /0/1//Ya. /1k/1//74.a -c-. , 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 omply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissa own r shall notify th immediately. <br /> <br />Date 3 Signature <br /> <br />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 T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />ost \02L-i