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SAN AA( ,1N <br />COUNTY <br />Environmc .al 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 />1. To be completed by APPLICANT <br />Owner/Operator Name <br />Business Mailing Address I 6 I-191 EGr 0 M. C-I* S LE rd CATbN CA 75207 <br />City S TT> State_thZip 95.2.09 Bus. Ph/co:I-Sig 72:5- Alt. Ph. /6 t / i <br />, 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 pi <br />Signature <br />nalties. <br />Business Name ,S'4CK 44CK y Asii . sEri <br />Lic. Plate # p s 3 <br />Date <br /> 21 - 2.0.2D <br />1 2:To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name SaCialKILS WO C-P-CA FA# <br />Address (Li 30 -A-ST WE 13ER„ A-cie • Bus. Phone 2..cq - 2.3 <br />City STZCThit) Zip .-1c2,0‹.- Owner/Operator e--e-10A cw-duncl Log k <br />Check all appropriate services providec/ <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 />astewater disposal <br />Et Solid waste disposal <br />Hot & Cold water for cleaning <br />1:4 Store dry food/supplies <br />3-compartment sink <br />Food preparation <br />173 Store refrigerated food <br />1..:;!Overnight parking <br />Erge-ctrical hook-ups <br />0 Toilet and handwashing <br />0 Potable water <br />0 Vehicle wash <br />commissary o,wnr shall notify the ,EHD .mmediately. <br />Signature <br /> LAut-- Date <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