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SANJOAQUIN Environmental Health Department _lr —COUNTY— AW gro:•.s here. COMMISSARY AGREEMENT Mobile Food Facility ♦ Caterer Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. 1. To be completed by APPLICANT_ q Business Name �rDCfl7 CSN �D7��r�U�GX / CP CAe& w. Plate# "7 7 / 9 f J3 Owner/Operator Name ,--ts,,-e - _j Ll M l Ui Business Mailing Address �'S3 � - 1;40AA-1<1SY Ri VE City Sf�C 'T�� State<fXZip g 2_ Bus. Ph.-D-0��11 OS'Y I' Alt. Ph.OZ6 FEE /Sf C)1dL4 h4(. (2 hereby state that the above information is current,true and correct to the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the commissary is discontinued,the,permit holder must notify the EMD. Failure to notify this office may result in permit revocation and penalties. Signature A^0 Fn . CfnaAu.,,,p n�q Date 2 O 2-1 2. To be completed by COMMISSARY OWNER/OPERATOR Commissary Name 6T60-q_b•U S CL)0 A bEl� ILIL FA# Address /L-( 3Q E ' W E f3t�f*\ AI)C ' Bus. Phon�el Z-P) City �� 7V Zip 9 S 20S' Owner/Operator V'i`e 0,:T CkC1i-4 ),tA - Check all appropriate services provided: 13 Wastewater disposal D 3-compartment sink 13 Electrical hook-ups ❑ Solid waste disposal ❑ Food preparation ❑ Toilet and handwashing ❑ Hot&Cold water for cleaning ❑ Store refrigerated food ❑ Potable water ❑ §tore dry food/ upplies ❑ Overnight parking ❑ Vehicle wash I, "o G/(. , hereby state that the information 1 have provided is current,true and correct to the best of my knowledge,and meets the Califomia Health&Safety Code requirements. If the food facility operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the commissary yowl er shall notify the EHP immediately. g� i t- 1 Q - ZU 2l Signature t p Q� -{,St " dN warn Date o 3. To be com leted b the urisdietion outside of San Joa un Co. The commissary is located in County. The above food facility meets the commissary requirements in California Health & Safety Code. The above checked services are available at the above commissary. Please notify EHD if the status of their operating permit changes. REHS Signature Date 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd