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SANJOAQUIN <br /> <br />Environmental Health Department <br />—COUNTY <br />Gre:-..7.tni?ss <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 completedy APPLICANT <br />Business Name NO 640 -6Z 4-bi • - <br />Owner/Operator Name )1_11 Li 1\4 iN14.1) <br />Business Mailing Address 4 coo rmuto 64„ -Tr•-, Joe, <br />City •&A-51\-N To 14 State OA- Zip qs f5? A Bus. Ph. 9 2-c-14 2,C ---7-2-;"2_ Alt. Ph. (,So S-2-2 o4 it 2_ <br />I, 1 , hereby state that the above information is current, true and correct to <br />the best of my knowledd.'e 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 dis9erinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and p n lti <br />Signature <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Solid waste disposal <br /> O Food preparation <br />[(VV)stewater disposal <br /> O 3-compartment sink <br /> 15t11.-0-erical hook-ups <br />e-T_9i3efnd handwashing <br />F>table water Hot & Cold water for cleaning O 99re refrigerated food <br />'Vehicle wash Store dry food/supplies Ye-Overnight parking <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 ma ified or cancelled, the <br />commissary owner shall notify th HD immediate <br />Lic. Plate # <br />Date <br />Commissary Name \ <br />Address 19 eAD •`-7 • <br />City L-viiErT._m,oz_,--Ei zip C)4S51 <br />Check all appropriate services provided: <br />c71 FA# <br />Bus. Phone C)2_c -44-7 -7 17 ç6 <br />Owner/Operator E-1) <br />Signature Date <br /> <br />3. To be completed y the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in 11- e 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 />REFIS Signature eAr Date \2-3 <br /> <br />1868 E. Hazelton Avenue Stockton, California 95205 I T 209 468-3420 F 209 464-0138 I www.sigov.orgiehd <br />Cf--0s0 s