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To hcompleted by COMMISSARY OWNER/OPERATOR <br />Commissary Name COMmlaSckly F.J G /jô 1 JJX.FA# <br />Address •3S Ade_ Bus. Phone ZO ct --3.3. Li-Z.573 <br />City LOC-I Zip qsz "i0 Owner/Operator A1 b'+ g Le cSy <br />Check all appropriate services provided: <br />3-compartment sink <br /> <br />74Electrical hook-ups <br />Food preparation Toilet and handwashing <br />Store refrigerated food ?!c-Potable water <br />Overnight parking ?,Vehicle wash <br />, hereby state that the information I have provided is current, true and <br />Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br />Store dry food/supplies <br />Coev ,o, Aar- <br />SAI\ JOAQUIN <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 />To be completed by APPLICANT <br />orsp 9 -04uy <br />Business Name tviT f'}ciko, cwci-c cu,61 tr-ccOs Lv 17r-r1 Lic. Plate # 9 Vf5 5-6 17) <br />Owner/Operator Name 1\ii ay, iu lbernvio e-? " 7 \ <br />Business Mailing Address 6rr--33&vit PevIc Cif • <br />City Loblvt() State CA Zip Is--47t Bus. Ph. (q02')9-92:3 12Alt. Ph. <br />I, f‘kT\11-kCJO \--)E4/1U19 - , 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 END. Failure to notify this office may result in permit <br />revocation al s. <br />Signature j jib Date i2)//314 :2 Y <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 e EHD immediately. <br />Signature 4/4 Date - 2,0Z. <br />To be c pleted 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 T 209 468-3420 F 209 464-0138 I vvww.sjgov.orgiehd <br />PROSIA Gt DO