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SAN JOAQUIN <br />—COU N TY- <br />Greatness !paws h1. <br />OSROS2_ <br />Environmenta 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 />To be completed by APPLICANT <br />Business Name C, 00 oa Lic. Plate# o y,325,2 \) I <br />Owner/Operator Name ;) /06- A iu (cZ- <br />BusinessMailingAddressss 13 (05- u I a to ST <br />City c)-lb (g.-10/1 /4 ) Statee4 Zip c:1)6 ic Bus. Ph.20C))00r" Y9 1- Alt. Ph. <br />I, lUajirt cc-A,r) ju.4 , 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. <br />Signature ... j 0, \ .5 (-_,,k,(vc a Date // <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name )/JO/) C A-7, 7-4(K. 0240 <br />Address 111 3 3Ot ki Bus. Phone 2061 zqk 51-1J-L- <br />City ,10C-1. 7(14J zip 9 5,)r) 6 Owner/Operator On) kult)(3- <br />Check all appropriate services provided: <br />Ai Wastewater disposal <br />tx- Solid waste disposal <br />14 Hot & Cold water for cleaning <br />Stor dry food/sup <br />ar:.) <br />correct t the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply wi conditions of this agreement, or if this agreement is modified or cancelled, the commissary owner s EHD immediately. <br />Date <br />To b 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 />REHS Signature Date <br />1868 E. Hazelton Avenue 1 Stockton, California 95205 I 1 209 468-3420 I F 209 464-0138 www.sjgov.org/ehd <br />3-compartment sink <br />Food preparation <br />IQ Store refrigerated food <br />21 Overnight parking <br />tElectrical hook-ups <br />Toilet and handwashing <br />,KPotable water <br />)(Vehicle wash <br />, hereby state that the information I have provided is current true and <br />Signature