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AN JOAQUIN <br />—COUNTY <br />Grea tness grows he, <br />revocation and altie <br />Signature Date <br />Environmental Health 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 />t To be completed by APPLICANT <br />Business Name t,( 1 10 ICA c..-O <br />Owner/Operator Name Do 0 c eti Sa ttc keZ— <br />Business Mailing Address .301(101 605419,e, C4) CA y <br />City 5 kt,14, itit/ State CA Zip 9500‘ Bus. Ph.(209)606C.YCL' Alt. Ph. <br />I, rPCivv,c SCAy-\ c Vle 7 , 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 .loaquin County Environmental Health Department (EHD) requirements. If the use of the <br />commissary is di continued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />Lic. Plate # (.A \ \ <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />FA# 1-11(AT Si 5 i( <br />ecA-s* 1.4 c_10--kAj OU Bus. Phone c2octj LE Co c-t- s- C' <br />City 5k-oc-J-ti-DYN CIA Zip (1-1620 5 Owner/Operator (3-1 c-ke\i? " -4Ar <br />Check all appropriate services provided: <br />--EkWastewater disposal <br /> g 3-compartment sink <br /> Electrical hook-ups <br />>6,- Solid waste disposal <br /> 0 Food preparation lt Toilet and handwashing <br /> <br />Hot & Cold water for cleaning <br /> 0 Store refrigerated food <br /> Potable water <br />0 Store dry food/supplies <br /> Xi-Overnight parking -Et Vehicle wash <br /> <br />e)Ct, rCe. R. CI S , 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 sharnotify the EHD immediately. <br />- <br />Signature <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 />RENS Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sigov.orgiehd <br />Commissary Name <br />Address ct <br />Lek <br />Date -