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SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY - <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 />L i To To be completed 4y APPLICANT <br />Business Name (o'tcroe Lic. Plate # \NJ 0 314 <br />Owner/Operator Name V c,-k--0 r 'c pck_ckpleco <br />Business Mailing Address L4O 5(kr:ju.itne -1--+; 'pc--# -7- 0 <br />City 5+Dc,K,v1 State - Zip q52-02 Bus. Ph. 2-01 -2-167-Alt. Ph. <br />I, Vi 0-0 n'cA- atc eco , 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 Date 0 -712 0Z- 1-1 <br />gel? <br />Address 6?-0 2T e <br /> A73-e 4-- <br />Bus. Phone (76 2'1/ r3.3 1 <br />City )--01), zip Z.TO Owner/Operator <br />Check all appropriate services provided: <br />ar<astewater disposal <br />3-compartment sink <br />114olid waste disposal <br /> <br />Itiood preparation <br />12K-lot & Cold water for cleaning <br />Eir tore refrigerated food <br />/Store dry food/supplies livernight parking <br />A7_ ,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 Date <br /> <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 Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-34201 F 209 464-0138 1www.sjgov.org/ehd <br />pezd Ooz23 <br />Commissary Name FA# <br />th,‘ectrical hook-ups <br />riVfoilet and handwashing <br />eiP9table water <br />10(Vehicle wash