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A QU I N [Envoronmantal Heakh Department <br /> riAk� _C 0 U N T Y-- <br /> Grcotn��!s graws <br /> COMMISSARY AGREEMENT Vvyr\Q — c_,2,,� c, <br /> Mobile Food Facility ,, caterer fT-�100-e <br /> �s <br /> Complete secffons I and 2- If your commissary is located outside of San Joaquin-County also&6iripl6f6-se6i ion 3 <br /> Business Name Pffil-L U qA L 2-crr&,5 Lic. Plate# <br /> Owner/Operator Name A f I I-7c 111,;2 <br /> Business Mailing Address ut� <br /> - 2 <br /> city StateLA—Zip.0:3 Bus. Ph.2Q9-Y)_?-6jCj /�—AIt. Ph. <br /> I— VIC-7()K �24A411C&L , 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,&� <br /> Date cc) <br /> L2. COMMISSARY OWNER/OPERATOR <br /> Commissary Name 114 LIUA _CAltOIG, TCv(v c Lz FA# <br /> - <br /> Address .1 -7 17 3- ovick) '!In Bus. Phone <br /> City-Sa-0bC_10 /U' Zip—q-572-0-b Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal M 3-compartment sink M Electrical hook-ups <br /> V�11 Solid waste disposal _0 Food preparation X Toilet and handwashing <br /> Hot & Cold water for cleaning ZM Store refrigerated food Potable water <br /> Store dry food/supplies 02 Overnight parking Vehicle wash <br /> Q10i�KA_ 1�63 A —, hereby state that the information I have provided is current, true and <br /> corre&t to the best of my knowledq"nd meet-the California Health &Safety Code requirements. If the food facility <br /> operator fails to compl t,,"ditions of this agreement, or if this agreement is modified or cancelled, the <br /> ,_ �r- . <br /> commissary owner s C=)b e D immediately_ <br /> Signature Date <br /> 13. -Toy: OMPleted.b. the ENV HEALTH jurisdiction outside of San Joaquin C--o--.-- <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 1 T 209 468-3420 1 F 209 464-0138 1 vMv.sjgov.org1ehd <br />