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MISSARY OWNER/OPERATOR To be completed by C <br />/119 ,2-27L /0 <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY— <br />Greatness grows here. <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 (3 vi(ZIA Q DI FAIT 6,47 P*12.1)_ Lic. Plate # <br />Owner/Operator Name t.),-) Ft '3.- b <br />Business Mailing Address 6 6 5 u3 • u.) 6 uLetz__ 1-\\J e • <br />City MOVNTAW -*)ate OA Zip 153°11 Bus. Ph. 134 61/ tt.30 Alt. Ph. <br />W 411b S'Yei> , 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 Cot nty Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinued, t e ermitfloNer must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />Signature Date /0 ' 0-7-- • a-OL-9 <br />Commissary Name \-ocNvot <br />Address kv) LsN)cc,xo Bus. Phone 204- 6''3- et 41z. <br />City -\--oc,v_ Zip 93-7...oz Owner/Operator 03.-1/4)\ <br />Check all appropriate services provided: <br />ErWastewater disposal IIII-<-compartment sink Drnectrical hook-ups <br />WS-aid waste disposal (2--frnod preparation 113-1-Oilet and handwashing <br /> <br />& Cold water for cleaning a're refrigerated food rP,--rOtable water <br />Tre<Tre dry food/supplies 1210.9veFftigilt-paresiRg -4.,eitigii*e=svaela <br />I, 5 (iv\ We-Z , 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 all notify th HD immediately. <br />Signature <br />To 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 />Pk2s co 20 <br />Date t - - -Lc° Z-(-1