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Commissary Name i lz„--iece <br />Address 670 6 5 At4 40 A-- <br />FA# <br />(z061> z21/-g S39 Bus. Phone <br />SANAOAQUIN <br />-COU NTY <br />'‘,041Siory <br />Greatness grows here <br />/a. 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 />To be completed by APPLICANT <br />Business Name I ogytki,,, Cork_ Lic. Plate # M 1,-ti q 6 <br />Owner/Operator Name p-cyi vi/k.) llytk-iti gfrticitia <br />Business Mailing Address Ci-0 1.• ctkertitifial iv 5/- <br />City J O (6 stateCif Zip C, Bus. Ph. 70q Z(3f)C 2-Alt. Ph. 2--O ci 5 2-cly2„7 <br />, 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 71•Nnalties. <br />Signature #14t..4.1S, 1411 Date <br />To be completed by COMMISSARY OWNER/OPERATOR <br />City (..._6+ 21 Zip 95-Z W Owner/Operator <br />Check all appropriate services provided: <br />EiKastewater disposal 11:14:compartment sink <br />OVS-olid waste disposal b)Food preparation <br />IZK-Hot & Cold water for cleaning S re refrigerated food <br />alt-ore dry food/supplies Overnight parking <br />/14-inAdve. <br />Electrical hook-ups <br />E <br />WfO:a et and handwashing <br />Potable water <br />EKehicle 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 />commissary owner shall notify the E i cpmediately. <br />Signature Date <br />3. To be completed 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 />/cz av ;2"-- <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 />1R 0 SY'q' S5 \to