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Business Name <br />Owner/Operator Name iCed iLeOnDifaSqk <br />Lic. Plate # 4NY3 94--, <br />.„,.., : SAN JOAQUIN <br />' ------ C 0 U N T Airr.rear <br />- -,, Greorness grows here. <br />Environmental Health Department <br /> <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 />1. To be completed by APPLICANT <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 (END) 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 />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name coecmik rape FA# <br />Address 65-( Eovii-rs e. 51e4i1 2 0-5- Bus. Phone 9I&P - q6' ---/2-04 <br />City &cm/4-701/v zip 9 -'i7z-S Owner/Operator A-OVrt-Sql- <br />Check all appropriate services provided: <br />,ErWastewater disposal 0-'3-compartment sink ,-ErElectrical hook-ups dSolid waste disposal ___P-Food preparation -Cr-Toilet and handwashing <br />4:1Hot & Cold water for cleaning J2tore refrigerated food otable water <br />.EeStore dry food/supplies El Overnight parking D Vehicle wash <br />I, 1/40 V-.tovi.,0-cr-ktik , 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 wne shall notify the EHD immediately. 1 <br />To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in s'A-% ' 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 (-6/ 2-3 /2.L. <br /> <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/end <br />FR25 00061 0 <br />Business Mailing Address (8.S'0 Aiffe-)v) <br />City Slioe.k .‘1 State OA Zip 675-PIO-- Bus. Ph. qi&--99*--/2-01-Alt. Ph. <br />I, to 14.A3tA,Q1-1x.,S4.,_ <br />Date •--( 7-3 (Z.3 <br />Signature Date ()ST IL 2431.-k.\