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SANAAQUIN <br />COUNTY <br />Environmental Health Department <br />Greatness o - <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 APPLICANT <br />Business Name I N. 01 AA/ cilACK iIOI la Lic. Plate # I/5 <br />Owner/Operator Name it-mo-e.arr Si (v6 <br />Business Mailing Address <br />•)1 f <br />Cityryej1-1.)-C StateCA Zip 953 Bus. Ph 09-3A—c17vt. Ph. <br />I, -1 ICTIZAV13 (ji r4 , 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. j <br />Signature (Pao-AA Date <br /> <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name (,;e/vii-eitS....Wy (t.116) FA# <br />Address jUi/ S 5sJ S7 taria7 Bus. Phone (9y.)e; G6T - y <br />City Zip 9(1 //0 Owner/Operator ; <br />Check all appropriate services provided: <br />Wastewater disposal <br /> o 3-compartment sink <br /> <br />0 Electrical hook-ups <br />a Solid waste disposal <br /> <br />O Food preparation <br /> Er Toilet and handwashing <br />Hot & Cold water for cleaning 0 Store refrigerated food <br /> <br />fiV Potable water <br />0 Store dry food/supp,lies a Overnight parking <br /> rI Vehicle wash <br />/1/3 1-11:1, 7 , hereby state that the information I have provided is current, true and <br />correct to the best of my knowleige, 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 §J.aIl notify the E imediately. <br />Signature Date <br /> <br />3. To be completed by the iV 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 />RENS 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 />WO 94 %zol