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Business Name 1[01 <br /> <br />6-row16_s <br /> <br />Lic. Plate # <br /> <br />Owner/Operator Name 1- ,L <br />„4 <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />--COUNTY— <br />Greatness grows here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Complete sections 1 and 2. If your commissaty is located outside of San Joaquin County also complete section 3. <br />1. To be completed by APPLICANT <br />1 Business Mailing Addrpss at [O fl 9 I <br />City (7-1-0 c,L.1-D17 State (Zip Bus. Ph. UO1) 2„---0,0 Alt. Ph. <br />A idt. , hereby state that the above information is current, true and correct to <br />the best of know!” da rand 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 pe alties. <br />Signature <br />To be completed by COMMISSARY OWNER/OPERATOR <br /> ;yditiq <br />Commissary Name 9Af a(7-1(/(--- FA# <br />Address 33 C 100))01- Bus. Phone 09 ?"-n g-) <br />City (.."*TVA zip 6. 2- Owner/Operator 1 titF tito-flM 6 <br />Check all appropriate services provided: <br />Wastewater disposal <br /> <br />C'compartment sink <br /> Electrical hook-ups <br />1.134.-Ood preparation <br /> 1I1-Toilet and handwashing <br />EckSibre refrigerated food <br /> <br />&Potable water <br />Overnight parking <br /> Vehicle wash <br />, hereby state that the information I have provided is current, true and <br />ledge, and meets the California Health & Safety Code requirements. If the food facility <br />the'-conditions of this agreement, or if this agreement is modified or cancelled, the <br />e HD immediately. <br />Signature <br />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 />°StA ql <br />Date Lf ) <br /> <br />Solid waste disposal <br />111---ribt & Cold water for cleaning <br />T-Store dry food/supplies <br />I, AlA4V-C-- 14/1 /41-rt <br />correct to the b9t of my_kno <br />operator fails to 'Com iy Wit <br />commissary ow r sh <br />v Date <br /> g