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SAN,JOAQUIN <br />—OUNTY — <br />oGreo riness grows her?. <br />Environmental Health Department <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 />t <br /> <br />Business Name "TIN C 0 S El 1.0‘Kfiu,e,,,;?q) Lic. Plate # /-1)C 3(a I (P <br />Owner/Operator Name -SO r q e, Lc) , 5 ((&s+ Fle-acA <br />Business Mailing Address to -_)_,2) 5 NI e.,;.) bo 0 (ci 1{/-- <br />City .\-0,001:Prl StateCA Zip 015 210 Bus. Ph. Alt. Ph.c2a (1) -715 - 29 61 <br />I, -. \ 0 r cAC.- L- i..o 1 5 0'6 klijotteick, 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 1,-___Ic_i penalties. <br />Signature <br /> <br />‘-e-r en {ve rcakcon • F A# <br />Address 0.-g 6 0 E a.,64 atr- luccil Bus. Phone ()-0 61-) L-1' - 1/S 70 <br />City eDkocKfo-r) Zip 95 c Owner/Operator G-F-. "C V1 <br />Check all all appropriate services provided: <br />tit Wastewater disposal <br />ja Solid waste disposal <br />Si-Hot & Cold water for cleaning <br />0 Store dry food/supplies <br />A v\-CA CDO-r-C12-rvc,,,,S , 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 Z.-- <br />H EALTHIO 00' <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 />Date - - 2_0 a-cf <br />Commissary Name L c). <br />11 3-compartment sink <br />Food preparation <br />Store refrigerated food <br />jit Overnight parking <br />la Electrical hook-ups <br />121 Toilet and handwashing <br />)2( Potable water <br />Vehicle wash <br />Date <br /> V2-- 1 9) - <br />Date 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 />PROG (0 SS1