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t` <br />C <br />-77 SANJOAQUIN <br />COUNTY <br />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 />GO' s Pi zpt- <br />Business Mailing Address <br />City 6att Statei Zip 6tS4L57 Bus. Ph010 3?)5--4t3-4 Alt. Ph.2.a1)(60-4 CR6 61 <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 and enal ies. <br />Signature 4-4 Date F10 2s 2C 2S <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name & bleAtic FA# zoi-3--;(1-as 0 <br />Address 555 1,,j built\ Bus. Phone( 2o1) 31.. ,Li - 2S9- 3 <br />City La li zip q 5 246 Owner/Operator AI be ri---c-) A10-fer <br />Check all appropriate services provided: <br />Business Name <br />Owner/Operator Name F',CIUC1 Y.(T0 el( 3-rry.nr) <br />Dcwin9 <br />Lic. Plate #4 <br />&Lev/it) 60alevin <br />4Wastewater disposal <br />Solid waste disposal <br />rfCt-lot & Cold water for cleaning <br />Store dry food/supplies <br />j6 3-compartment sink <br />Food preparation <br />Store refrigerated food <br />I‘Overnight parking <br />Electrical hook-ups <br />lIfToilet and handwashing <br />l‘Potable water <br />Vehicle wash <br />A, 4 hereby state that the information I have provided is current, true and <br />correct to the @est of my owledge, 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 noti the EHD immed. ly. <br />Signature Date a -ZS • 70 75T <br />3. To be mpleted 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 />1868 E Hazelton Avenue I Stockton, California 952051 T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />NO5 LI 19 ILI