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SAN .10m:will <br />4 ris f-** <br />Environmental Health Department <br />Greatness grows here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility. Caterer <br />Complete sections 1 and 2. If your commissaty is located outside of San Joaquin County also complete section 3. <br />To be completed by APPLICANT <br />Lic. Plate # 1/(i5L10 Z <br />, -1;4 &200.1 , 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 pe alties. <br />Signature <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name C-c-k j fn Sp FA# <br />Address 2 Ve) 9vr\-- CA.,(A:i Bus. Phone cf — cL I I 46-6 <br />City ut. h9,A Zip qclo6 Owner/Operator cq ) c, At->1 BL4.,,,•.. )-t :) <br />Check all appropriate services provided: <br />Business Name hike t ITU,ktey LLc <br />Owner/Operator Name .-170A ?DtowlA <br />Business Mailing Address 193 3 6.11(_Aly-pl Pic <br />City C--4(1 jaCIA StateLA Zip qs-zoci Bus. Ph. &Pi-7'40:535Y Alt. Ph. <br />Date <br /> z <br />If Wastewater disposal <br /> is( 3-compartment sink <br />a Solid waste disposal <br /> <br />El Food preparation <br />Hot & Cold water for cleaning gi Store refrigerated food <br />ai Store dry food/supplies -14 Overnight parking <br />Electrical hook-ups <br />10- Toilet and handwashing <br />Et Potable water <br />Eli Vehicle wash <br />R—Nikko , 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 notify the EHD immediately. <br />Signature <br />3. To be completed 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 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />Date ti(2-4 <br />Date