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_ 'S�Oo'B 2 8 b2 <br /> �Q .° � SAN�IOAQUIN Environmental Health Department <br /> " ' COUNTY <br /> Greotness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 9 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_ 1,t t rt E�1 l I C_ .)~ (�jY`� Lic. Plate# q 7-0 7,3 <br /> Owner/Operator Name "~ r reifl j* <br /> Business Mailing Address SCt, 12 tJEL L PZ <br /> City NAN-rECM State C�ZiBus. Ph(�-00 3.2,9 - 09?l,Alt. Ph • r6) q3 <br /> I, c O E ;FW s H 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 penalfes. ' <br /> Signatu Date //3 r 0 2- <br /> [2, To be com leted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 416 (C,- N c`0 lrel M G _rkdC K L0tr6"FA# <br /> `7 <br /> Address 17/ S . L4/0c%Ai` S` Bus. Phone(.269) '-29S-Sm1 <br /> City.5-70_C,&1_0W C-4 Zip '520 Owner/Operator film ARD-t-' <br /> Check all appropriate services provided: <br /> U/Wastewater disposal U16-compartment sink 12"'Electrical hook-ups <br /> 'Solid waste disposal .L_�/Food preparation E3"Toilet and handwashing <br /> lam" Hot & Cold water for cleaning © Store refrigerated food M/Potable water <br /> Store dry food/supplies Lg/Overnight parking II/Vehicle wash <br /> 1,__ ler_ �/?,4'y6 _ , 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 /> Signatures Date <br /> . 3. To be com leted by the ENV HEALTH jurisdiction outside of San Joa uin;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 952051 T 209 468-34201 F 209 464-0138 j www.sjgov.org/ehd <br /> �V'05gOW Is <br />