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SAICJOAQUIN <br />—COUNTY <br />Greatness grows here. <br />Environmental Health Department <br />fRO'S-(4 g S-Liq <br />• <br />COMMISSARY AGREEMENT <br />Mobile Food Facility 4 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 it -A. c L [ CI r629 Lic. Plate #,c. 876 <br />Owner/Operator Name/ 0 ,f5 Er fiefiii <br />Business Mailing Address/ t,c, pa_netacr.e.t.T, irc./ o ad C roP1 <br />City mod bnr:tile_statec A. Zip 9 7 liev7e1(yAlt. Ph. <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 penalties. <br />Date -2- 2S <br />To be completed by COMMISSARY OWNER/OPERATOR <br />(,o/-flitilSIG/^),-- t - ''Q A FA# ?- Commissary Name <br />Address 3 SS M 6,// 4vit. Bus. Phone '—g---16%-V----- <br />City (i Zip ?C; C70 Owner/Operator Y- ?-r7:3 Lc/ <br />Check all appropriate services provided: Al e(-76 /-1/,‘,-/-/- z..., <br />Ff. Wastewater disposal ?. 3-compartment sink 0 Electrical hook-ups <br />,Zr Solid waste disposal E3 Food preparation 53 Toilet and handwashing <br />16 Hot & Cold water for cleaning Store refrigerated food pi Potable water <br />0 Store dry food/supplies 701 Overnight parking tliZr Vehicle wash <br />NI-er /7-le , hereby state that the information I have provided is current, true and <br />correct to the best of my knowl ge, and meets the California Health & Safety Code requirements. If the food facility <br />I, 4, <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall notify e jp imm diately. <br />Signature Date <br />To be completed by the E EALTH 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 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />Signature CP