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Signature <br />SAN JOAQUIN <br />COUNTY <br />Grfotnes:; 9re,‘.5 here. <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility 9 Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />-,e:r4o.tifootei.:tii..* APPLICANT <br />Business Name Lic. Plate # 91/ 7 <br />Owner/Operator Name <br /> <br />Business Ma' ing Address .7.5.-e 3, 4 . ' i ale--e ' <br />City . Statee0 Zip3'c/r Bus. Phi97 — ?/Y 37 Alt. Ph. <br />1,, c; /401/0 60/1424 le.. - , hereby slate 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 !ties. ..,:c___,,_ <br />1Wriib.61:0ithbleted b COMMISSARY OWNER/OPERATOR <br />Commissary Name. <br />Address 9M E.(2tv,A.,z1:17( 4.i) <br />City D I} , ZIP KA46-- <br />Check all appropriate services provided: <br /> <br />FA# <br /> <br />Bus. Phone <br /> <br />Owner/Operator City <br /> <br />ra 3-compartment sink <br />it Electrical hook-ups <br />Food preparation Toilet and handwashing <br />CI Store refrigerated food <br /> <br />6 Potable water <br />6 Overnight parking <br /> <br />6 Vehicle wash <br />, 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 />mply with the c itions of this agreement, or if this agreement is modified or cancelled, the <br />shall notify t HD immediat . <br />Signature Date Ve....0 7-2,CA <br />Wastewater disposal <br />d] Solid waste disposal <br />Ei Hot & Cold water for cleaning <br />9,tTe dry fed/supplies <br />I, (4A44 id- <br />operator fa' <br />commiss <br />to <br />own <br />Date//a <br />erCOrnpfeted,by the ENV HEALTH jurisdiction outside of San JoaqUin <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 />112o301131