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. _ <br />c. <br /> SAN JOAQUIN Environmental Health Department <br />COUNTY <br />Greatness grows here. <br />0 P17 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 Ar'114 F () C°61/a" Lic. Plate # J13S-89- <br />Owner/Operator Name Davt, Ay.f0 (Ot <br />Business Mailing Address 2-`I 3 4peCt -, Ct`rz-i-e <br />City -C1-17c-F°'\ State C-74- Zip 91-2-`) Bus. Ph(1)9E1— . Alt. Ph. <br />1)acrA--)-r6Ltd6 , 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 penalties. <br />Signature <br /> <br />Dr- <br /> <br />Date #59'. l(-0•2-.9-2-2_, <br /> <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name tt IV) ( 01)1s c 6-r-6 ki IQ (..k .1-(ZUO, Ce(1--t-,f, FA# <br />Address if 7 ( 7 6,. 0.Aleeiti ,517 Bus. Phone (“ci) .R c(S^541(L <br />CitySric(KkAli (in Zip 26--2e4- Owner/Operator ,mr (/O' <br />Check Check all appropriate services provided: AiZ , srer,ticii6 <br />Ej(VVastewater disposal 0 3-compartment sink 0 Electrical hook-ups <br />0"- Solid waste disposal 0 Food preparation 12{Toilet and handwashing <br />i'.2/Hot & Cold water for cleaning 0 Store refrigerated food 1:24)otable water <br />0 Store dry food/supplies 0 Overnight parking ILOVehicle wash <br />I, A RT-' i r (42/) o , 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 er shailL-rugy the JD immediately. <br />Signature <br /> <br />Date 44 6I•Z- A 62- <br /> <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 />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.org/ehd