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NINJOAQUIN Environmental Health Department <br />COUNTY <br /> <br />Greotness grows here. . _ <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 />To be completed by APPLICANT <br />Business Name 210 -C!-5 <br />Owner/Operator Name itio OV/ LE_S <br />Business Mailing Address 9?9 S iiicerrLsorL 371-- 4!1(- <br />City ,51t,C.X1Fr..) a State Ca Zip V.5.204 Bus. Ph. 2.oei qz3 Vg‘Z_Alt. Ph. <br />Ake_ A. , 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 penalties. <br />Signature Ake_ /1.. 6/t/ders <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name ?" 1ç Ili FA# <br />Address 6 zo c ‘-5(6 r41"'"b" Lc4"-- Bus. Phone (?ô) 7Z.1)/ — g jy <br />City t D Zip 410 Owner/Operator A t rit e., 'to oe-6.4._ <br />Check all appropriate services provided: <br />rerastewater disposal,„. _ <br />"Solid waste disposal <br />rii4ot & Cold water for cleaning <br />CP-Store dry food/supplies <br />I, /4 71 , hereby state that the information I have provided <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified <br />cothmissary owner shall notify the EHD immediately. <br />Signature <br /> <br />Date <br /> <br />_Citii).1151.0ted...13,ithe'ENUMEALTH]drigd.10fdfiIiiitOIdei,lOti,$efili$44-uiri:C <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 />WOSLIC;) <br />Lic. Plate # (LS 04)3 <br />- Date <br />1/3-compartment sink <br />(3Food preparation <br />VS-tore refrigerated food <br />13/6vernight parking <br />O'ffrectrical hook-ups <br />4;ilet and handwashing <br />a 1/:otable water <br />hicle wash <br />is current, true and <br />If the food facility <br />or cancelled, the