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SAN JOAQUIN β€’ Environmental HeaKh Depaanerit <br />COUNTY <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 DoS_ `q H f42-g Lic. Plate # 5:6399 Li (0 <br />Owner/Operator Name 1\7 auf"? ,I 1=6 .3R t2.- <br />Business Mailing Address Li Li t95 vvrt`i City 31DUcrb kistate_chzip 15 2M1Bus. P to2-1F15 ph( ?0S1 5 ILIF) <br />It .1.- 1.)I) -1- Fp B I2-DOhereby 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 Iscontinued, the pe it holder must notify the EHD. Failure to notify this office may result in permit revocation an <br />Signatu el.9e,e'l <br />Date ?. 1 1- 201.5 <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary NameU NiN comivviSS,If-Y-r-F-ucigN61 FOIVIT <br />Address 11 li Si U MON ST Bus. Phone 201 i N- SL/! tto <br />cityj1cir-41)N Zip °IQ.. 0 U Owner/Operator 124),c1 FEN f TIP-ADO <br />Check all appropriate services provided: \ I OifILN i i-eir " <br />X Wastewater disposal X) 3-compartment sink . Electrical hook-ups <br />Solid waste disposal 1 Food preparation '-..] Toilet and handwashing <br />Hot & Cold water for cleaning Si Store refrigerated food Potable water <br />A Store daf food/supplies ':Overnight parking Vehicle wash <br />I, '/E I KA SOS-A , hereby state that the information I have provided is current, true and <br />correct to the best of my icnowl and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to cornrr nditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owne A TIT o w k itβ€” , - HD immediately. "r7 1 <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 1 209 468-3420 I r 209 464-0138 www.sigov.orgiehcl <br />PRO530t102 <br />Signature Date I /?,U9 76 1,5