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SQNsJ0Q0UIN ` Environmental Health Department <br /> ►,I, � COUNTY <br /> r _ <br /> ?. Greatness grgws here. <br /> � Co <br /> COMMISSARY AGREEMENT iilg � ' tas .x; <br /> Mobile Food Facility ♦ Caterer --� 209. 20005389 <br /> Complete sections 1 and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br /> eterdla' 'Af!PLI:CANT <br /> Business Name ale <br /> G (Za Lic. Plate#—'aJ 7i22�j1 <br /> Owner/Operator Nam KO Cc, y--e- <br /> Business Mailing Address 9 S (,&- fC oh , v-d i, <br /> City State�A Zip .7 Bus. Ph. (2 c7�i) It. Ph. <br /> r e , 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 a <br /> Dake <br /> i2:,sT6,�be:comoleted b.. COMMISSARY OWNER/OPER 4TOR <br /> C6mmissary Name r' CC <br /> m• ` LEA# <br /> Address /L-ts re Bus. Phone <br /> City e/y 4 _ 1 Zip g53 Ownerloperator <br /> Check all appropriate services provided: <br /> III-Wastewater disposal 0-3-compartment sink -0'Electrical hook-ups <br /> 13 Solid waste disposal WFood preparation Ef Toilet and handwashing <br /> 0 Hot& Cold water for cleaning 0 Store refrigerated food Potable water <br /> 13 Store dry food/sup li s WOvernight parking vehicle wash <br /> I, k'7 , 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 noti D immediately. � <br /> Signature Date ',c" _5 --Zv Z 15::, <br /> 3 VJ!K coin 'lete~he EN HEALTH urisdictian,outslde of.San�J.oa uid4o:T- <br /> The commissary is located in 1` >E}K,IS 11�}VS County. he 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 1 7625 <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 i F 209 464-0138 1 www.sjgov.org/ehd <br /> W2�3Lit <br />