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Signature v <br />SAN JOAQUIN <br />COUNTY <br />Greqt.ne!;5. grow5 here, <br />Environmental Health Department <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 />t.:TO rniketed1)YAPPLICANT <br />Business Name <br />Owner/Operator Name/i9a)1j4. <br />Business Mailing Address /3070 teAd j <br /> <br />Lic. Plate # MC -07-5 <br />A/44:e1-1107140 giASa <br /> <br />City State 6/I-Zip A,e,c,' Bus. Ph.r -g5Y-4/SY Alt. Ph. <br /> , hereby state that the above information is current, true and correct to <br />the best of my knoWled e and agree to utilize my approved commissary in accordance with California Health & <br />Safety Code, and San Joaquin County Environmental Health De artment (EHD) requirements. If the use of the <br />commissary is discontinued, the permit holder must noti D. Failure to notify this office may result in permit <br />revocation an. nal 'es. <br />Date -02c0 <br />2. ote.cOrnpledl by COMMISSARY OWNER/OPERATOR <br />Co r FA# <br />Address c2_ ck 6 0 E •ckormi u3c1 Bus. Phone 4-1(ec1-- Lig-70 <br />City (3c-i-t-k Zip 9 5-1.1) S Owner/Operator , ''Ck t)ci cp --,--1 <br />Check all appropriate services provided: <br />47(Wastewater disposal jd. 3-compartment sink g Electrical hook-ups <br />,r0olid waste disposal El Food preparation Ek• Toilet and handwashing <br />A. Hot & Cold water for cleaning L Store refrigerated food la Potable water <br />13 re dry food/ lies .Overnight parking IX Vehicle wash <br />I OAT/tl/- 7A-X <br />correct to the best of my knowledg <br />operator fails a omply with di co • di of this agreement, or if this agreement is modified or cancelled, the <br />commissa o er shall not the EHD immedia <br />41111W <br />Cornipletedby 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 />pcN cky'LtZ <br />Commissary Name L-c„, Co rri C-t <br />, hereby state that the information I have provided is current, true and <br />nd meets the California Health & Safety Code requirements. If the food facility <br />Signature Date <br /> —