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Complete sections 1 and 2. <br />SAN :Ai <br />COU N T Y----- <br />Grt3atnE?ss st rive.s he,, re. <br />Envh-onmental HeaOth Deparkment <br />0\)eCf;.5 <br />pcNr c/dr- <br />\r-\Q — cori,xp 0\ 4- <br />o p-ec <br />If your commissary is located outside of San Joaquin-County also -comPlete section 3. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br /> <br />Business Name K A--Tri-L6V14 10763 <br /> <br />Lic. Plate # TZe6q3 <br /> <br />Owner/Operator Name V 1(-1(,‹ <br /> <br />Business Mailing Address p (---/ 7301(5070 <br />City 310 Mic, Ai State 061- Zip Oi 32_0 coBus. Ph.2 OCi -/Alt. Ph. <br />I, <br /> <br />V 704 /WU/CC: , 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 Date 0/ <br />Tabexcernpletedsby COMMISSARY OWNER/OPERATOR <br />Commissary Name tik/i(jili Noi7,emii.--T zetick- C(L---4_,7,,,CFA# <br />Address / -7 17 3 - (Jove/0 Y7 Bus. Phone 2-0(1— 2 cps--- t-.4.4 I (0 <br />City SI 0 QIC1-0 iki Zip q 5 - 2,_o C, Owner/Operator . 1 O5i k( .. mi.--; 77,e4-aa <br />Check all appropriate services provided: \KiCA\r\ on' if Wastewater disposal Mil 3-compartment sink 1M Electrical hook-ups <br />'e Solid waste disposal 'r---:1 Food preparation Toilet and handwashing <br />77Z- Hot & Cold water for cleaning C Store refrigerated food F Potable water <br />0 Store dry food/supplies Ell Overnight parking IC Vehicle wash <br />I, PS K A- ç 65 Pr , hereby state that the information I have provided is current, true and corre t to the best of my knowled nd meets the California Health & Safety Code requirements. If the food facility operator fails to compl t ditions of this agreement, or if this agreement is modified or cancelled, the commissary owner s D immediately. <br />5 e--///02o, Y Signature Date i <br />To. -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 END if the status of their operating permit changes. <br />REHS Signature Date <br />1868 E. Hazelton Avenue! Stockton. California 95205 I 1 209 468-3420 I F 209 464-0138 I vtrww.sjgov.org/ehd