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3-compartment sink <br />Food preparation <br />Store refrigerated food <br />)6 Overnight parking <br />Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />Vehicle wash <br />, hereby state that the information I have provided is current, true and <br />21-6/ <br />CAW <br />jurisdiction outside of San Joaquin Co. <br />Date <br />00A, <br />SAN JOAQUIN <br />,0 - _COUNTY <br />0 451X411:77 <br />Environmental Health Department <br />Greatness grows hef, <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 />PoTRotvi> <br />Owner/Operator Name M:tncy G5c-iv -iye/ <br />Business Mailing Address 60y3 a 6cccc L0 <br />City Ructimniis State_CA_Zip 9536/ Bus. ph.zo?SgS /232 Alt. Ph. zo9568 Z6g4:7 <br />1, PanCy 5oratu-su e , hereby 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 pe alti <br />Signature <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name )4 afrt Elan 13,0 1W 68LF b1oafte6-FA# <br />Address WO p(rf -IserSal 124 Bus. Phone bog 539 6/03 <br />City Ol i.)cr6on15 zip CII 9530 Owner/Operator RoSin ClarK <br />Check all appropriate services provided: <br />Wastewater disposal <br />1:1 Solid waste disposal <br />Hot & Cold water for cleaning <br />Store dry food/su plies <br />I, PO VOA TS <br />correct to the best of my k ledge, 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 />if the Rime <br />3. To be kcompleted by the EN <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 />72%O5 t fl-to <br />Business Name L.Ci Lic. Plate # 31 35-993 <br />Date 05/WLV <br />commissa <br />Signature <br /> <br />er shall n <br />