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City <br />SAN JOAQuilN <br /> <br />Environme.al 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 />1. To be completed by APPLICANT. <br />Kt,r&i 0C Lic. Plate # -71?) La-T2_. Business Name <br />Owner/Operator Name T)8 -1?_.10A-Vin- oe <br />Business Mailing Address 9,0 • (6)( / 1 <br />oY1 State CM-zip 9S-3(03us. Ph. 3e)2---6/ Alt. Ph. (i.o7-701-/Y' <br />, hereby state that the above information is current, true and correct to <br />the best of my knowledg 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 peri.it • lder must notify the EHD. Failure to notify this office may result in permit <br />revocation . • •enalties. <br />Signature <br />2. To be completed by MISSARY OWNER/OPERATOR <br />Commissary Name axi(oti FA# <br />Bus. Phone c)cd Address / 7 7 s, qtutc, -5-R 6 f <br />Owner/Operator City _517D c-K -For-ii Zip <br />Check all appropriate services provided: <br />E'Wastewater disposal <br />olid waste disposal <br />-1.3'7-Hot & Cold water for cleaning <br />/Store dry food/supplies <br />(1(3-compartment sink <br />13ZFood preparation <br />EStore refrigerated food <br />1:1(Overnight parking <br />EV'Electrical hook-ups <br />ETToilet and handwashing <br />E.313otable water <br />13/\/ehicle wash <br />, 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 tify the E,HD immediately. <br />Signature 17 - <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 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />Date 2 .2 /402 ° <br />iber -7-7/M6 0 <br />Date .24y