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Commissary Name 1.1 ro, L ATer)" <br />- <br />Electrical hook-ups <br />'Toilet and handwashing <br />Dr Potable water <br />L' Vehicle wash <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />---COUNTY <br />Greatness grows here. <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 completed by APPLAGIANT <br />Business Name eLi;r -v.)-4 YvV) 00A) CcVrT Lic. Plate # ;?-3 'V 7.3 <br />Owner/Operator Name rc 62--e._dp at" <br />Business Mailing Address '2,0(1-..0 kets-Vk t/e, <br />City 540c_ kiev\ State (A Zip¶\5 1 c'C Bus. Ph. Alt. Ph. goS 491 9(3 6 S <br />, 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 Date i 202 <br /> <br />:2. To be completed by COMMISSARY OWNER/OPERATOR <br />Sp FA# <br />Address 2- 9 VO • A fgor Bus. Phone 7..o ci c 1 / Yt <br />City Sl-z7 K Zip 61 cl-C2-6 Owner/Operator <br />Check all appropriate services provided: <br />ta Wastewater disposal <br /> <br />al 3-compartment sink <br />-0 Solid waste disposal <br /> <br />Ei Food preparation <br />54- Hot & Cold water for cleaning <br /> 4 Store refrigerated food <br />Ex Store dry food/supplies Overnight parking <br />1, e- lzuht , 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 /> Date I 74 / <br />3. 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 1 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />1, <br />Signature