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City c:,3v Zip c3c2.07 Owner/Operator <br />Check all appropriate services provided: <br />-12- Wastewater disposal <br />cl-Solid waste disposal <br />EtsHot & Cold water for cleaning <br />0 Store dry food/supplies <br />3-compartment sink <br />Food preparation <br />Store refrigerated food <br />PL--Overnight parking <br />' „ <br />' <br />< —COU NTY----- <br />Greatness grows here. <br /> <br /> <br />Environmental Health Department <br /> <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 />To be completed by APPLICANT <br />Business Name I 'DEA) lcE CREAtv\ <br />Owner/Operator Name Z. A1-1 RA/ El <br />Business Mailing Address TO. 130)C 4, 9 30 5.4-- <br />City 9115 e 4300 State404- Zip9,52_/0 Bus. Ph. Alt. Ph. <br />1, OA k i t{ PC r vt 5 , 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 andzpanal s. <br />Signature Date 0 ) <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Lic. Plate # <br />Commissary Name <br />Address q-,40._ <br />6L j. <br /> <br />FA# <br /> <br />Bus. Phone .°),---)41,-9 Lj k4 <br /> <br />U) 3 <br />12tElectrical hook-ups 0 <br />1:clroilet and handwashing0 r4 4 <br />X m •••1 G) <br />0 g 0 z <br />0 <br />I, ct-INA vri cc...A et , hereby state that the information I have provided is current, true ITI <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food tali... 0 <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, •""" <br />'S i• us a <br />3. 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! F 209 464-0138 I www.sjgov.org/ehd <br />0 Potable water <br />13 Vehicle wash <br />commissary owner shall notify the EHD immediately. <br />Signature Date