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SAN JOAOUIN <br />, COUNTY <br />Greatness gr:ow5 here, <br />PQ15COS21 <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 />0..,..0617600041*APPLICANT • <br />Business Name <br />Owner/Operator Name j e,suS . Corfl *v=i1gbato <br />Business Mailing Address 41'- ‘/ 5', 04710,1:0-11-11., <br />City 3-7:06t.tri, Statedil Zip/5W4) Bus. Ph.a1/-,017 4Y-D?iffAlt. Ph. <br />I, 7?; 5115 migei_ 4-g fio tit) , 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 ermit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation jj. senalties. <br />_Lic. Plate # e-pi7g66 <br />Date 4,2 ot5- Signature <br />2. Tb e Conijaieted by OMMISSARY OWNER/OPERATOR <br />Commissary Name <br />Address 2- c-t 0 <br />Check all appropriate services provided: <br />FA# <br />Bus. Phone c2-c-c1) L1C(' q C-7 0 <br />Owner/Operator 6_çz.l` 0 II -A- evye:d- <br />L_Ck <br />City c-,k-c,C, <br />Aflk.1 <br />Zip crS <br />3-compartment sink <br />Food preparation <br />Store refrigerated food <br />Overnight parking <br />, 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 omply with the conditio s of this agreement, or if this agreement is modified or cancelled, the <br />commissary pn shall notify th E mediately. <br />131 Wastewater disposal <br />13 Solid waste disposal <br />Hot & Cold water for cleaning <br />0 ye dry food/supplies <br />ON44:-.k. 4-77/(04dez____ <br />Electrical hook-ups <br />IS Toilet and handwashing <br />Ei Potable water <br />El Vehicle wash <br />Signature Date — 4-77 <br /> <br />a be Corn'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