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revocation and a es. <br />Signatur <br />SAN JOAQUIN Environmental Health Department <br />COUNTY <br />Grecitne:Es gro;.ys here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility 4, 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 />tA I 3 <br />Business Name A•() e-A-i eu &la ---J/1?-411,-3-e Lic. Plate #r,c 9) z? r 4-5-01-10.9q <br />Owner/Operator Name 1.-‘ <br />Business Mailing Address <br />City (L'i 2 aP. State (A Zip 3604 Bus. Ph. zryi 6'2 12,Alt. Ph. <br />Qt,vj•c,,, , 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 J•aquilicataunty Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discon ed, the per t holder must notify the EHD. Failure to notify this office may result in permit <br />Date / 2 / Lt <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />FA# <br />Bus. Phone 0:1"1 21V- <br />City <br />Commissary Name <br />Address 15-g N aadl /5111- <br />) Zip _5-)-(//) Owner/Operator <br />Check all appropriate services provided: <br />0- Wastewater disposal icir 3-compartment sink <br />tU Food preparation <br />Store refrigerated food <br />pi Overnight parking <br />IA Solid waste disposal <br />IF Hot & Cold water for cleaning <br />13 Store dry food/supplies <br />cc i <br />pr Electrical hook-ups <br />prToilet and handwashing <br />,Er Potable water <br />pr Vehicle wash <br />I, /)-e,) Cro PZ,-- <br />, hereby state that the information I have provided is current, true and <br />correct to the best of my know ge, 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 shal otify the HD im diately. <br />Signature Date 67-.)- k , <br /> <br />HEALTH jurisdiction outside of San Joaquin Co. <br /> <br />3. To be completed by the E <br /> <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 />RENS 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 />Pg114 Do (I) %