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Owner/Operator Name A ,12-c3;50 <br />Business Name <br />SAN JOAQUIN <br />OUNTY <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 />I 1. To be completed by APPLICANT <br /> Lic. Plate # <br />yok 0 <br />Business Mailing Address Z-1 <br />City teia,wi-t 44.0,>-,„,. Stater-4n. Zip 41S-W11 Bus. Ph.Lta3 -5017-0525 Alt. Ph. 310 -9 9q--(c62q b4A <br />.3,61,- Aw_ce-c) , 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 <br /> <br />&/-t/-z- (f <br /> <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name '-a.._./ _C--0\c--(e___ FA# <br />Address 2439eP:7 c..- Itia41,44,"/" 3--- Bus. Phone 2_,D.- 630-- /'6 <br />City I J-7-,c-c-c- Zip 9537 -?- Owner/Operator <br />/f- \- Check all all appropriate services provided: ‘1,- 1 <br />V - it.‘c--(-e_ <br />El Wastewater disposal 0 3-compartment sink Electrical hook-ups <br />Ei Solid waste disposal 0 Food preparation IX Toilet and handwashing <br />Hot & Cold water for cleaning 0 Store refrigerated food "ES Potable water <br />Store d7 food/supplies PrOvernight parking 0/Vehicle wash <br />I, Z. .-OL CP c_.11' , 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 no ' y the END immeately. <br />Signature --e X)-- Date 6 -2-/- Z '1 <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 <br /> <br />Date <br /> <br />1868 E. Hazelton Avenue I Stockton, California 95205 I 1 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd