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Environmental Health Department <br /> 1 SANJOAQU � N p <br /> l:_■s i".y C O U N T Y----- <br /> Greofness gfuws Vtr <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 /> 1: To.°be completed'b� APPLICANT <br /> Business Name C__-> cls Lic. Plate# .5 N (90, <br /> Owner/Operator Name_+ ct I1 +'? pock (1A(A1 . n <br /> Business Mailing Address <br /> City S30 C'P'+ ` StateCA Zip iSZ1S Bus. Ph. 2cii— Alt. Ph. <br /> I fin; (1 Nck PU&g<z , 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 J/n��rJ��"^J Date <br /> =2_..T6 be com ,Ipted b. :_COMMISSARY OWNEPIOPERATOR <br /> Commissary Name cLt FA# <br /> Address- 2C1 0 01 Bus. Phone ?-G �1 `��Y `�S� <br /> City Zip 51765 Owner/Operator Cr - 2- '` C h,Q AKVl <br /> Check all appropriate services provided: <br /> Wastewater disposal r,3-compartment sink Electrical hook-ups <br /> Solid waste disposal 0 Food preparation 43joilet and handwashing <br /> -Hot & Cold water for cleaning 0 Store refrigerated food potable water <br /> ® Store dry food/supplies III Overnight parking P(Vehicle wash <br /> l , hereby state that the information I have provided is current, true and <br /> correct to e best of my Knowledge, <br /> and <br /> o#the <br /> s agreement orbit thisSafety <br /> agreement requirements. <br /> modified or the <br /> cance�edGthe <br /> operator fails to comply with the conditions <br /> commissary owner shall fy the EHD immediately. , 1 x9 f 2� <br /> _ `T Date— <br /> I- <br /> -3 To be pm leted b -the`ENV HEALTH jurisdiction outside of San.Joa uin;Co: <br /> County. The above food facility meets the <br /> The commissary is located in <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 <br /> REHS Signature <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 i www.sjgov.org/ehd <br /> R05Z q�3S <br />