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'°'--c% SAN JOAQUIN Environmental Health Department <br />COUNTY <br />F. <br />Greatness grows here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility 4, 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 />Business Name is-77f8 r 26 <br />Owner/Operator Name pay) <br />Business Mailing Address tiq /3 lino <br />City Stet Zip <br />aaf <br />Lic. Plate # <br />vaAe Dr <br />Bus. Phc &.)i.3(1,--9321 Alt. Ph. <br />I, /1_,19.44 , hereby state that the above information is current, true and correct to <br />the best cy .wledge d 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 pena <br />Signature , Date / <br />2. To be complete. sy COMMISSARY OWNER/OPERATOR <br />Commissary Name (A•t,S ?tRyiniv:krkr-,1k.r.r FA# <br />Address 7313 U-) £-tLector-- Bus. Phone (20'k) 41(0 • SOGS <br />City 57-0 OCTIZ)i--) Zip 957.-t 0 Owner/Operator <br />Check all all appropriate services provided: <br />[Si/Electrical hook-ups <br />13Toilet and handwashing <br />12Kpotable water <br />0 Vehicle wash <br />, hereby state that the information I have provided is current, true and <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 ow er shall noti the EHD immediately. <br />Signature <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in 5-c.k, 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 />m4/astewater disposal <br />o Solid waste disposal <br />EirHot & Cold water for cleaning <br />GrStore dry food/supplies <br />I, doc-i- r411511C_ <br />1E/3-compartment sink <br />rFood preparation <br />4tore refrigerated food <br />Overnight parking <br />Date 37114( 20 29 <br />REHS Signature „ Date <br /> <br />1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />VIZOC-D4 Clk)-2)-7)