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SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />Greatness grovvs 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 />Business Name K INC DIM ROCK Ki Lic. Plate # 9 91 5 X3 <br />Owner/Operator Name v.) PIL31 -1 <br />Business Mailing Address 82_0 n 1Y) rn Oda t Laf CIR kr) (315 2N <br />City State Zip Bus. Ph. 20q --- 8 (1,- 91,4 3Ait. Ph. '20q -3 ) <br />Kct vILK1 alii , hereby state that the above information is current, true and correct to <br />the best of my kRZwledge 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 rmit holl/- must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />Signature 1-Qnc / 5/ 2 ul Date <br />2. Tote completed by COMMISSARY OWNER/OPERATOR <br />It(---1614/-5 i ,t)0ApERFL-1-/— ff_e c-F fP f" <br />Commissary Name( <br />Address / H 3ô- & 'A) es 02 <br />City 3 TV Cf<T6 )"-) Zip Qc- , ZCS Owner/Operator <br />Check all appropriate services provided: <br />o (wastewater disposal <br />0' Solid waste disposal <br />& Cold water for cleaning <br />1:Itore dry food/supplies <br />I, Ue-PA OVAA vi (A) <br />commissary er shall notify the EHD imti ediately. i A. <br />Signature \/ C, Date 4; <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 www.sjgov.orgiehd <br />PRIL-took-13 <br />Bus. Phone ,7Z0 - 7 3 <br />ve-em cc_ C-it c-v-PAtA) t <br />‘ompartment sink <br />EirFood preparation <br />0.-S*re refrigerated food <br />Er6vemight parking <br />EiElectrical hook-ups <br />Cr-Toilet and handwashing <br />Cr-Potable water <br />&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 />2)-(