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SANAAQUIN <br />A 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 Vern IcCoS <br /> <br />Lic. Plate # 713 "2- <br /> <br />Owner/Operator Name Pan; el <br />Business Mailing Address j U. 611r le5 Avt <br />City /40de S State (4 Zip 95350 Bus. Ph. di) 12-1- 0.5 Ait. 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 />revocation and penalties. <br />Signature Date <br />, 2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name J42 ,(5 kilt" " C FA# <br />Address I 2. \ S13." 54 14 od e.5A-o, CA 95351 Bus. Phone (2.0q) 335-36, 6 <br />City J4oco Zip c1535 t owner/Operator (,), aerk cc, <br />Check all appropriate services provided: <br />v-Wastewater disposal <br /> <br />V'3-compartment sink $---Electrical hook-ups <br />"--Solid waste disposal "-Food preparation .."Toilet and handwashing <br />',Hot & Cold water for cleaning Store refrigerated food <br /> <br />ViDotable water <br />Store dry food/supplies 't)vernight parking "Vehicle wash <br />I, /4cm-h. Los cArz- , 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 to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall noti the EHD immediately. <br />Signature Date 0 5/V/29 <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in "-10,-+-,\ a ':"S (L)--/A-k, -( County. The above food facility meets the <br />- <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 Z <br /> <br />1868 E Hazetton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 484-0138 f www.sjgov.org/ehd <br />\22L\ 00211+