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SAN JOAQUIN <br />COUNTY <br />Greatness 9r0W5 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 />Lic. Plate # <br />Date 3- /,,,Z -.2006 <br />1. To be completed by APPLICANT <br />Business Name ad /e1,( <br />Owner/Operator Name Li \i' c ,S+ Op <br />Business Mailing Address I Ct 0 $ TUX-ed 0 a v C._ <br />City ,()(_, VOIJ State{} Zip 9.uot k Bus. Ph. 2-01 603-9f0 Alt. Ph. <br />I, 0-. (( ek-- , 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 Iti s. <br />Signature <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name KING- ISIAIQ E'tse FA# <br />Address (I 630 IA) 1 61-4-1- m Le AP Bus. Phone 'if-A, --141-1- S3 frq- <br />City grOCA61-7,-) Zip S 24 9 Owner/Operator CA I p.,Les sP14,eu, <br />Check all appropriate services provided: <br />43 Wastewater disposal <br /> ja 3-compartment sink <br /> <br />O Electrical hook-ups <br />a Solid waste disposal <br /> ja Food preparation Toilet and handwashing <br />'Hot & Cold water for cleaning <br /> I3 Store refrigerated food <br /> Et Potable water <br />Store dry food/supplies <br /> 0 Overnight parking <br /> O Vehicle wash <br />I , ---'1APW/eS , 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 EH mmedi tely. <br />Signature <br /> <br />Date L__?-12.-0 2.„5-- <br /> <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 />TRost-NiDo