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SAN JOAQUIN <br /> <br />Environmental Health Department <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 />To be completed by APPLICANT <br />Business Name (,1-1 LL L Lic. Plate # <br />Owner/Operator Name <br />Business Mailing Address -3k-i Lir- —1L1 <br />City St,c .4-, State L- l zip c7S-re,. Bus. P.1I GI c I 3Li Alt. Ph. •-)) C '2..) -7/ <br />11 rA , hereby state that the above information is current, true and correct to <br />the best of my kiqowledge aild 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 f j <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Cr erli14 1- s()c-.._! y I Gci Ho 47-- JUC__ FA# 2_47- .34 /. 1/50 <br />Address .2) 5 3 ,L.) • c,,," Id Ao c_ Bus. Phone 7eq -3-28 , 157 3 <br />City Lc)cit (' Zip 7 5 7 11 (. /Owner/Operator A) be / 4?-i lik_o. r ?' u 1-• zi <br />Check all appropriate services provided.: <br />astewater disposal 3-compartment sink *Electrical hook-ups <br />'ci(Solid waste disposal 0 Food preparation 16.Toilet and handwashing <br /> <br />p(Hot & Cold water for cleaning 0 Store refrigerated food * Potable water <br />0 Store dry food/supplies /If—Overnight parking ehicle wash <br />I, C.A.i 1,,,,Ani y A/Ict r i „.., r- , hereby state that the information I have provided is current, true and <br />correct to thefbest of myknowledge, 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 immediately. <br />Signature 4.----- _.— Date G6. r; 2-C3Z-7 V <br />To be pleted 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 />W15o0Q-09-- <br /> Date