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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 />Owner/Operator Name 1-7"A1v% A-0.fat <br />Business Mailing Address 2-(4"-- APC <br />City StOdc-kv r) State afr Zip Bus. Ph. (lo 9 ) cs-'(-k-i=0 Alt. Ph. <br />parrt,_ Atyotca, , hereby state that the above information is current, true and correct to <br />the best of nil}, 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 Date t c) • ° <br /> <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name LAAV,t) Li.)\--1 TC FA# <br />Address go ,35 riw- D F Bus. Phone 5 8S8t C <br />City \--tpv.,Jp,n Zip C:\ Li...Suo Owner/Operator V--P-Ifk ‘Y) g <br />Check all appropriate services provided: <br />gi Wastewater disposal <br />0 Solid waste disposal Fdatian Toilet and handwashing <br />7431-1 Hot & Cold water for cleaning G'Store refrigerated food <br /> <br />Lai Overnight parking —Vehrcte-riv—• ash -• SIP <br />I, Pvt Ik In q N CI,14 v11- , 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 ner shall noy th EHD immediately. <br />Signature cl..\\ Ofvk 1 V` Date I o) cl) <br />To be completed b 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 HD if the us of their operating permit changes. <br />SAN JOAQUIN <br />COUNTY <br />riq 0 3 0S-1 Environmental Heath Depd fflerr <br />Business Name A 3sA(dA Fovd (Dopy, Lic. Plate # <br />Gti. <br />rtg Electrical hook-ups <br />PotaPie water <br />REHS Signature Date 19 /05 )ZZ <br /> <br />Stockton, California 95205 l T 209 468-3420 F 209 464-0138 1www.sjgov.orgiencl 1668 E. Hazelton Avenue