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SAN JOAQUIN <br /> <br />Environmental Health Department <br />--COUNTY--- <br />1!.=F30."' <br /> G reotness grows he,7 r,?, <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 Lia <br />Owner/Operator Name C).--tWev sk-c. Kat)YMS <br />Business Mailing Address 344.—S .4- <br />Cityl2Avevtanic, State (Pt Zip Cl3(04. Bus. Ph .1 gas 33Alt. Ph. <br />I, G166/ CID VtOS , 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 /> <br />Date -1/ 1 (1/q <br /> <br />To be côfnpleted by COMMISSARY OWNER/OPERATOR <br />Commissary Name & GICLUO COM VS S Cot- t_ FA# <br />Address 1*()\ 5 SaLvayrtei'*--4) %Sk--- Bus. Phone <br />City Z-onf ; Zip 052_y D Owner/Operator <br />Check all appropriate services provided: <br />ta Wastewater disposal <br /> O 3-compartment sink <br /> O Electrical hook-ups <br />13 Solid waste disposal <br /> O Food preparation <br /> O Toilet and handwashing <br />Hot & Cold water for cleaning <br /> o Store refrigerated food <br /> O Potable water <br />Store dry food/supplies <br /> O Overnight parking <br /> la Vehicle wash <br />1, vaerk-r_., , 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 n ify the EHD immediately. <br />Signature <br /> <br />Date <br /> <br />3. To be mpleted 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 />Lic. Plate # 4 03-1.G9 <br />WZ9A 3'Y2_