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SAN JOAQUIN <br />—COUNTY -- <br />Environmental rlealth Department <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 />Pe' a ValrOl'f <br />Business Name Aftxicci. <br />Owner/Operator Name AAKO rov, (/ A.,-V5 n <br /> <br />Lic. Plate # L-11/K2 5(e2_ <br /> <br />Business Mailing Address 1--)-) lae For+ Au .e <br />City C'-`1V(40)0State(61. Zip G W E Bus. Ph.(2,09 -110 Dolt° Alt. Ph. <br />I, AdvorA A-St7') , 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. kiu <br />AF . 0. <br />Commissary Name 4 Z-4L-e-ce- <br /> <br />F <br /> <br />Address '7 Bus. Phone Eze,l) <br />City 2--(4)t <br /> <br />Zip 9 SZIo Owner/Operator A-hytoire. <br /> <br />Check all appropriate services provided: <br />aj4/astewater disposal Kcompartment sink <br />IVYSolid waste disposal rikKo-d preparation <br />ri4t & Cold water for cleaning ali,‘-ore refrigerated food <br />Store dry food/supplies ti/Kternight parking <br />in-‹-ctrical hook-ups <br />Wrollet and handwashing <br />a <able water <br />wash <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 modified or cancelled, the <br />commissary owner shall notify the EHD immediately. <br />Signature Date <br />Signature Date <br /> <br />: <br />I 14,,,,14.4114a1MF e • IP • <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 <br />?R 0 91 VI 3