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SAN MAK <br /> <br />Environment Health Department <br />COUNT • <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 Vigt(E/un /t9gNc-1-0 Gkgm.ge Lic. Plate # ars-8706 <br />Owner/Operator Name GREGOto Gor\cztiL6 Z. entoNew <br />Business Mailing Address 2 2 9 76 /14i1x(PAS4 g <br />City E5 c1./Al State 'ftZip ?2(.) Bus. PI-Lzeq)6Us--916, Z- Alt. Ph. <br />GEV-- 601Zio G, Pdametzft , 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 anji penalties. <br />Signature t1991 ' /1 43f)ett/Z1 <br />To be completed by COMMISSARY OWNER/OPERATOR <br />W1110 Al efiralikiG 17t,t4k ceArink FA# <br />Bus. PhonePG <br />City 3 1-040-Vti, CA Zip 515-0?0 Owner/Operator 4R711efti6 0/0 <br />Date <br />Commissary Name <br />Address / 7/7 5 u/i)uvil ,s77 <br />Check all appropriate services provided: <br />Ile/Wastewater disposal W/3-compartment sink <br />[(Solid waste disposal riFood preparation <br />63/Flot & Cold water for cleaning 13S"tore refrigerated food <br />OVStore dry food/supplies flOvernight parking <br />6(Electrical hook-ups <br />aToilet and handwashing <br />El<-"otable water <br />tar Vehicle 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 ow,p.r shall notify the EHD i ediately. <br />Signature .,, Date 7/2_0 / ? <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 END 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 />1, RP e