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SAN JOAQUIN <br />—COUNTY-- <br />Greatness grow, 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 />1. To be completed by APPLICANT <br /> <br />-Tor -.1-k Pcc f1 tj Lic. Plate # kif V 2-7 (.0 <br />Owner/Operator Name Nktk b -CI YYN Nir <br />Business Mailing Address t'-12.0 t 4 ino <br />City Skock\-ern StateC Zip 9 5705-Bus. Ph. (NCO 5ô1 •-•332SAlt. Ph. <br />I, May 7e-1 PA Cty., , 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 />Business Name <br />Signature e Date Date <br /> <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name L CA co rn_e'C O. I CO) • FA# <br />Address 9, • v (It" ‘rt ki Bus. Phone 2-0 —L1 Co - qs 7 0 <br />City 54-tc-kko v--\ Zip 9S 2.0 S Owner/Operator cvki v ' A fzn.e. ft <br />Check all appropriate services provided: <br />10 Wastewater disposal <br /> <br />1131 3-compartment sink <br /> .251 Electrical hook-ups <br />El Solid waste disposal <br /> <br />O Food preparation <br /> Ili Toilet and handwashing <br />ja Hot & Cold water for cleaning O Store refrigerated food <br /> <br />ti• Potable water <br />0 Store dry food/supplies lit Overnight parking Vehicle wash <br />1A--v\ct PT-A' c.-e-no.S , 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 notify the EHD immediately. <br />Signature <br /> <br />Date <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 EHD if the status of their operating permit changes. <br />REHS Signature <br />1868 E. Hazelton Avenue I Stockton, California 95205 I 1 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />Date