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tr, <br />cLitv • <br />' C O . SAN:JOAQUIN <br />COUNTY <br />Environmental Health Department <br />1, <br />47.‘,., <br />•••-• Greatness 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 Co c-tkoNf.p \cE <br /> <br />Lic. Plate # <br /> <br />Owner/Operator Name cof..pi-1 /4 f,\i,r)E,t\ck<, <br /> <br />Business Mailing Address kkin <br /> <br />City C---ctr,c. ktrjm StateLA Zipc15.5..11; Bus. Ph. VA0.)kg0iii 01% Alt. Ph. <br /> <br />C-3:9•1A CDs tilf-1R6 , 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 <br /> <br />Date 612/ ILI <br /> <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 7iAL LI-0M (oikiLL FA# <br />Bus. Phone (a.c4) 114 I - 214 i Address CZ Dip,(4)Lo Ny e <br />City Zip CA5)-31) Owner/Operator 1,0\ 1AE LIN R -•;,3 <br />Check all appropriate services provided: <br />Et 3-compartment sink <br /> O Electrical hook-ups <br />IS Food preparation <br /> O Toilet and handwashing <br />Store refrigerated food <br /> O Potable water <br />Overnight parking O 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 />commissary ownerstiall ti D immediately. <br />Signature <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 />RENS Signature Date <br />IN Wastewater disposal <br />53 Solid waste disposal <br />El Hot & Cold water for cleaning <br />Stn dry food/supplies <br />KA.L(CC tiv\11(e1)-- <br />th <br />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