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• <br />I <br />S A N ski OAQUIN ca ° —COUNTY <br />Greatness grows here. <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 />1. To be completed by APPLICANT <br />Business Name <br /> <br />0 3 Pim 1(4, <br />Lic. Plate # L./ cz. <br />Owner/Operator Name L aRE /21---( TO (17)/146--z- <br />Business Mailing Address (36 I -ô Tr/ 1-) yEAZ <br />City FOCA'76N StateCfrZip 67S-0 ,06, Bus. Ph. c>2 09 99 2S:=2itrit. Ph. <br />I , L 612E- Lx ‘G <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 p naltiesj <br />Signature Date <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Si-(-) <br /> <br />C.K7Dij S /A) OA/ /, 41. FA# 0 6 43- 7'7 <br />Address LI D P,E. OC) Bus. Phone 02 0 9 9 ci <br />Zip e----2--\-)Oc- Owner/Operator 1)6--)eilo c.kf2,014 cuE-1 City <br />Check all appropriate services provided: <br />13 Wastewater disposal 0.--<compartment sink <br />13 Solid waste disposal EfFood preparation <br />0-1<ot & Cold water for cleaning 1:1--Store refrigerated food <br />ErStore dry food/supplies Ertvernight parking <br />Ergectrical hook-ups <br />trroilet and handwashing <br />Cr-Datable water <br />0 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 owner shall notify the EHD immediately. <br />Signature Date / 23/ 2O) <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 />RENS 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 />(2-- 2?- 2617