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SAN JOAQUIN <br />rw COUNTY <br />aroSeio- a‘ri Greatness grows 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 />To be completed by APPLICANT <br />Business Name C PA/Ni z-ce_ (Ilaf -A/v) Lic. Plate # L c <br /> <br />Owner/Operator Name C 1-1A-'V A-N <br />Business Mailing Address /g qti /v _ST <br />City Pvi 4 kirecti State C'4 Zip (-7,C37,2:?- Bus. Ph. 6 c--1-1PVISc71 73 Alt. Ph. <br />I, /V )244 11 , 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 />/7 ci-v)i/L-A <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name ft)27),V A) c-7--/q 1 /(.2 C/E.)06 /( FA# _ <br />Address 6" , ; ;'---- /12p-1 2c-- 777:' Bus. Phone ,' - S' 757- (--(iv/) 7 <br />City /27c/,.<-1-- S- 7-z.", Zip C L<-J- wner/operator /V19 rii 11 1/1--2 c- <br />Check all appropriate services provided: <br />Wastewater disposal <br /> o 3-compartment sink <br /> (--11 Electrical hook-ups <br />„pls.-Solid waste disposal <br /> <br />a Food preparation <br /> 4 Toilet and handwashing <br />_A Hot & Cold water for cleaning <br /> 423 Store refrigerated food c-19 Potable water <br />Store dry food/supplies cE1 Overnight parking (1?' 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 owner s all notify the EHD immediately. <br />Signature <br />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 H alt & Safety Code. The above checked services are available at the <br />above commissary. Please notify EHD if he tat of their operating permit changes. <br />Signature Date 0 2 -0 Z-5 <br /> <br />Date I / tif <br />RENS Signature <br />1868 E Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />TVit100211