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kir 3-compartment sink <br />[Et-rood preparation <br />110.'Store refrigerated food <br />CI Overnight parking <br />13 Electrical hook-ups <br />El-Toilet and handwashing <br />Potable water <br />o Vehicle wash <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />Greatness grows herc. <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 />Business Name t Lic. Plate # <br /> <br />Owner/Operator Name <br />Business Mailing Addrpss <br />City chc,1,,-1-6,() State (11-Zip q57,1214 Bus. Ph. __--2,eXi) 66 7,-C//Alt. Ph. <br />I, lt,k , ;•.st,' pv4 q n(rJ. , hereby state that the above information is current, true and correct to <br />the best of MS/ knowleid0 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 p alties. <br />Signature <br />2. 2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 4.2/417 1 - Li <br />Address 33 Avt-- <br />Bus. Phone 09 ) <br />City 1V4'\ 3-rteikf-'704Y\ Zip -C---;)1) 2— Owner/Operator ACWO (jE (A42-F2/ASIq <br />Check all appropriate services provided: <br />rif Wastewater disposal <br />IL,Solid waste disposal <br />& Cold water for cleaning <br />5.-tore dry food/supplies <br />I, MAE-- VA14"-VY , hereby state that the information I have provided is current, true and <br />correct to the beV of my kno ledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to om ly witlj the-cconditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary ow Lr shall ot4 te,FHD immediately. <br />Date <br />3. To be ompleted 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 />91Z054 (A 0 Grri <br />1 <br />9a ri(k. ke,- <br />Date (-1 <br /> <br />FA# <br />Signature