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SAN JOAOUIN <br /> <br />Environmental Health Department <br />—COUNTY <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 bezprivieted by. APPLICANT <br />r_ , k <br />Business Name .__JU <br />L <br />v--) Ni L (-A95 - Lic. Plate # 1--N A (01301 <br />Owner/Operator Name Ce\,\ [---6J V. IL, \_ ( f-L'k,MNI-(.., et,11.-- , _.1. t•:) z..-- - <br />Business Mailing Address 10 100 TrIV1-1A-\,1--- P6k1A4,04\-\ - , u--\..t-e-- 110 <br />City 547:z-N-Oli State 61 Zip 952161 Bus. Ph.7-09 s-.1 I , -7 I Alt. Ph.611 (01€ o (7(0 <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 />\ ,-"" y^. <br />12. To be completedtw COMMISSARY OWNER/OPERATOR <br />Commissary Name \ICAO Inor Siorckqc FA# <br />Address_ \ CLti-Alor 111%v 4.1 Bus. Phone C\q,- 4446 - ck -if <br />City Sr, cr rm.,st Zip c\Schl I Owner/Operator <br />Check all appropriate services provided: <br />th Wastewater disposal <br /> <br />3-compartment sink <br /> <br />V Electrical hook-ups <br />121 Solid waste disposal <br /> <br />12( Food preparation Toilet and handwashing <br />Hot & Cold water for cleaning n. Store refrigerated food <br /> <br />VI Potable water <br />0 Store dry food/supplies Overnight parking r Vehicle wash <br />I \•1 I c,.\ , 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 shill jiotty the EHD immediately. <br />i 1_(; 'LH Signature Date <br />3. To be completedby .the ENV HEALTH jurisdiction outside of San Joaquifi Co, j <br />The commissary is located in _...1,CLe101 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 n tify EHD if the status of their operating permit changes. <br />RENS Signature Itae- a0apl Date 1101-41 <br />1868 E. Hazeltun Avenue] Stockton, California 95 S5 T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />DSLI M <br />Signature <br /> <br />Date <br />