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SAN JOAQ1).14 Environmen.__I 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 cas os 7 5 Lic. Plate # I S 2- a Z- 7 Li <br />Owner/Operator Name 1C..I14)L L 0 2— <br />Business Mailing Address ti 6 .in Ry' CT <br />City 1T(1 C`.? State Cif Zip 9'5J n Bus. PhCiii25)62?-8Z 35— Alt. Ph. <br />1,R. c PROD L. C P2. , 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-disontinued, th permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation7and pe <br />Signature <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name It A) CATER N' er6 FA# <br />Address 7 I 7 ,S . co,fte /-* Bus. Phone <br />City 5 TO caO /.1) cft Zip PL.SrR C) 4 Owner/Operator ngr 77KA 0 0 <br />Check all appropriate services provided: <br />rar Wastewater disposal V3-compartment sink ISKElectrical hook-ups <br />, <br />9/Solid waste disposal iq' Food preparation ar Toilet and handwashing <br />12rHot & Cold water for cleaning k-.Y Store refrigerated food ('Potable water <br />["Store dry food/supplies tly Overnight parking avVehicle wash <br />I, #-R'T -RR fi D e) , 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 ownershalLnotftythQEL0 immediate <br />7z- 7cr <br />Signature <br /> <br />Date <br /> <br />To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in Toga \A 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 T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />crol)f Date <br />