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SAN JOAQUIN <br />—COUNTY - <br />6reatness grows here. <br />Environmental Health Department <br />-•C) L\ <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 />GO P r2Pr Lic. Plate #4 <br />Owner/Operator Name &,(-1 r ei ornfn <br />Business Mailing Address 1..)r <br />City 6Lift Statet Zip 11\657 Bus. PhHI ,5?.35---(40-11 Alt. Ph.206i)(6-iui c4-3-6 6? <br />iduiv(iio (0avvirl <br />Date T-t-1,9 2S 2cs2s <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Business Name <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 (END) 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 andenali ies. <br />P A flt(j4 Signature <br />Commissary Name E bit:!ruf ) <br />Address z-)55 <br />City Lc Zip q 5 240 <br />Check all appropriate services provided: <br />Owner/Operator be. /-1---c--) Akcxry u e7 <br />Bus. Phone( 2.(n) 33L-I - 2S4 <br />FA# Zo S <br />16 3-compartment sink 1,6 Electrical hook-ups <br />0 Food preparation ilfToilet and handwashing <br />qrLA-lot & Cold water for cleaning 0 Store refrigerated food lc Potable water <br />0 Store dry food/supplies fiOvernight parking t;6/ehicle wash <br />I, CUP,Aely A)01-?4,ze•-7 , 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 immed" ly. <br />Signatureii _/,'( Date a <br /> <br />by the the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> <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 END 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 />-93 Wastewater disposal <br />Solid waste disposal