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SANAAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />Greatness 9rows here. <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 tietainpleted by APPLICANT <br />Business Name 711C /.--.5 CA)) 4)/1- Lic. Plate # p v <br />Owner/Operator Name V 00,0 /-46, <br />Business Mailing Address 1 A) ce. v <br />City 97OCKA ,4U State CAT Zip (43-2o L, Bus. Ph.3.04 -c) L/Lci yklt. Ph. <br />y 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 ill Al/ We' nckel Date _2.- <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name (jA)/ 0 1U CA lie (I Or ( c-4 ALA# <br />Address ) ) 7 F? oti Bus. Phone 200 29S- - 5 19 <br />City SIOCK 70 A) Zip C) S2V e Owner/Operator 031 C-; -7At9() <br />Check all appropriate services provided: <br />/-41, .* <br />cx Wastewater disposal <br />0, Solid waste disposal <br />1310 Hot & Cold water for cleaning <br />p: Stor dry food/supplies <br />p, 3-compartment sink <br />gi Food preparation <br />121 Store refrigerated food <br />IS:Overnight parking <br />pr Electrical hook-ups <br />,13 Toilet and handwashing <br />pl Potable water <br />Vehicle wash f <br />u cO_Stit , hereby state that the information I have provided is current, true and <br />correc 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 c , ditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owners II notify EHD immediately. <br />Signature Date 2- \ )2.. 029 <br />3. To e 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 Stockton, California 95205 I T 209 468-3420 F 209 464-0138 I www.sjgov.org/ehd <br />POSLI1W