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"47 SAN JOAQUIN . <br />-COUNTY <br />osicx-dr-,„ <br />10Foat-4\ Greatness grows here <br />Environmental Health Department <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 />wdla C144v et ( <br />Owner/Operator Name Sct okcio,r Cal( a. 5 <br />Business Mailing Address 5g7alta.1444-61,veg <br />City GIZ)Ck-hyl State CA Zip 952-ic Bus. Ph. 2,0i- ‘1.1-0-4509 Alt. Ph. <br />I, S Atu ctdo,r CciA -ema 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 (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 and penalties. <br />Signature <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 1-61/4.ct C (-)c...-AY-b FA# <br />Address I '1 3 c‘ t 1>o eckdo s Bus. Phone 2o ci 2 ct 7_ • 8V2. <br />City S' Zip 5 2 b Owner/Operator Cdix-A ve-tu Cite ilqr re_ 2_ <br />Check all appropriate services provided: <br />E-Wastewater disposal er3-compartment sink l''Electrical hook-ups <br />ErSolid waste disposal riood preparation 0/1oilet and handwashing <br />ter Hot & Cold water for cleaning ErStore refrigerated food otable water <br />ICi -tore dry food/supplies ErOvernight parking 13 Vehicle wash <br />, hereby state that the information I have provided is current, true and <br />correct to the best of riiy 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 sh y the EHD immediately. <br />Business Name Lic. Plate # <br />Date V2-1/2-6 <br />1, Cdticto tirel <br />Signatur Date 2q 25- <br /> <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 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