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SAN JOAQUIN <br /> <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 />1. To be completed by APPLICANT <br />pt PINUY A <br />Business Name tviT f)}66-N rzc Lc D141 Lic. Plate # I/1.5 5C 1.7) <br />Owner/Operator Name 1\ /1.0(.1c .lbeittkefkri <br />Business Mailing Address (:Sc 3 Cit-itt Perk Q r • <br />City LC-A1/1t(1) State CA Zip IP,0 6 Bus. Ph. ((1-0):i92-3 2Alt. Ph. <br />I, f‘q1-1-\C \IC) ?-k—riVI UI9 , 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 d p al i-s. <br />Signature dr, Date <br />2. To completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name C Cowl 5Scki / 6 ce //(2 , FA# <br />Address 2,3S Ai C-)c.(Clci Bus. Phone 20 3 i - Z S 2 3 <br />City 1..—C)04 C Zip cr sz --/0 Owner/Operator A I be__An g cue Ady f <br />Check all appropriate services provided: <br />I, We v\d y , hereby state that the information I have provided is current, true and <br />correct to theibest 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 Date <br />9CWastewater disposal <br />IC Solid waste disposal <br />Hot & Cold water for cleaning <br />Store dry food/supplies <br />-163-compartment sink <br />rl Food preparation <br />J Store refrigerated food <br />7ZOvernight parking <br />lit!Electrical hook-ups <br />*Toilet and handwashing <br />i&Potable water <br />!KVehicle wash <br />3. 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 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />W051-10)001