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- Ulnj • <br />SAN JOAQUIN .ki7 . , -COUNTY- <br />\s,./ s... . Greatness grows her , <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 />To be completed by APPLICANT <br />Business Name CO C01.1-CA/i%111675- <br />Owner/Operator Name fh CIA CV1AA <br />Business Mailing Address VI 05 0 5+ - <br />City IT-Y*4 ijv-t State CA Zip 61ZOLPBUs. Ph. 201 • 'AP •1003 Alt. Ph. gel -L-Riv • eNto <br />1, CvlA (k2r , 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 />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name C AII coc-ru„ ter tn., S u 9 9 ij FA# <br />Address 2._ y vc2 c•>, Ate-Pcsr+- L,c y Bus. Phone 2 01 - co- t V6L <br />City ‘-) h)c v—i-z,n zip ,qc-Lo -c. Owner/Operator eS .7,4.IifiLu <br />Check all appropriate services provided: <br />40 Wastewater disposal a- 3-compartment sink WElectrical hook-ups <br />.0 Solid waste disposal a ,Food preparation Of Toilet and handwashing <br />III Hot & Cold water for cleaning p(Store refrigerated food I§ Potable water <br />El Store dry food/supplies 'Overnight parking 6 Vehicle wash <br />I, 'ee,-('-> 9 'UL.Q , 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 /> <br /> Date 1 /7. /7 ...„ <br />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 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />00130(40 <br />Lic. Plate # 3 6) g <br />Date