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SAN JOAQUIN <br />COUNTY— <br />Greornes5 - - <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 />I 1. To be completed by APPLICANT <br />Business Name Sc--- LL Lic. Plate # <br />Owner/Operator Name 1414L.,31 <br />Business Mailing Address -3C-100 Cc-Hre—ce. iLj -6r) <br />City St-crg.vv,-4---4-% State Zip -15-f:,;41-S- Bus. Ph. 034 Alt. Ph. cal / oo <br /> , 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 />12: To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name CriNAMI'SSC1/4..f / 2.. I G / /ô T'A)C_ FA# Z_) i - .,-,S( i . Ii SO <br />Address 2)53 „111/4) • Gct.i 14 Au e- Bus. Phone 70 -- -17.)(/ '157 --- <br />City („c)6 i: Zip 7 S 7, ti C)Owner/Operator be/ 4?-) )A-0, r?' U-e' <br />Check all appropriate services provided: <br />'VVastewater disposal r 3-compartment sink Nlif Electrical hook-ups <br />--, , <br />/3--/Solid waste disposal 7 Food preparation -T7-.- Toilet and handwashing <br />. ,r- <br />Hot & Cold water for cleaning 7 Store refrigerated food r; Potable water <br />'D Store dry food/supplies Ovemight parking Vehicle wash <br />y k.'! --- ,_ - - - - --- , hereby state that the information I have provided is current, true and <br />correct to theibest 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 />3. 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 />REFIS Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />'0g/503212_ <br />Date <br />Date 20,-f_y