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3-compartment sink <br />Food preparation <br />Store refrigerated food <br />Overnight parking Nr( <br />a(Electrical hook-ups <br />I./Toilet and handwashing <br />EVPotable water <br />arVehicle wash <br />0 9A \gtfl <br />SANdOAQUIN <br /> <br />Environmental Health Department <br />-COUNTY — <br />rovV5 hCre. <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't -*ARFIVACA <br />Business Name <br />Owner/Operator Name 9 50N ritY <br />Business Mailing Address (.01-kcA C,00\1ciyi ?\ <br />City k.A CXT\.\'-e-C,C).; State ON' Zip (A53 3 Bus. Ph. <br /> <br />Lic. Plate # A\/'I 2150 <br /> <br />Alt. Ph.1510.-30t-g3 <br /> <br />, hereby state that the above information is current, true and correct to <br />to utilize my approved commissary in accordance with California Health & <br />Environmental Health Department (EHD) requirements. If the use of the <br />lder must notify-the EHD. Failure to notify this office may result in permit <br />Date 2-V1-00-0/1-4 <br />2. To be comp <br />Address (0 a 01 1-1114,4 mj Fc11 Bus. Phone „:201 -7J2 itte ?4, <br />City 1.444 Zip 6 ;30 Owner/Operator <br />Check all appropriate services provided: <br />"Wastewater disposal <br />Ei Solid waste disposal <br />Hot & Cold water for cleaning <br />Store dry food/supplies <br /> , hereby state that the information I have provided is current, true and <br />L correct to the best of my knowledge i 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 own <br />AV <br />v hall no# e EHD immediately. <br />i Signature Af _ . AlIk Date <br />3. To b completedibOitielaWia 4iiiiitilOtionio.uticie4ot5ap4oactuiry <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.sjgov.org/ehd <br />AAArt ) d dc-e— <br />I, e•-ik -\'-k • 500'W • <br />the best of my knowledge and agree <br />Safety Code, and San Joaquin C u <br />commissary is discontinued, th <br />revocation and penalties. <br />Signature <br />:•1117 <br />Commissary Name lj 01-1< , ripoci PIA Z.A1 FA# 00,27193