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LI har=eir SAN JOAQUIN -COUNTY Greatness grows Environmental Health Department COMMISSARY AGREEMENT Mobile Food Facility. Caterer Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. To be completed by APPLICANT Business Name kiti €140l. -1-6.01Q e‘r‘'a Lic. Plate # (1 V F6E3/ Owner/Operator Name A4_:\Otho(y0 CoCrIe_7e_ Business Mailing Address IC G. S‘..a‘rra aja. r e e_-1- - City "\--00,6-00 State (A-Zip CfS9pcBus. Ph001195/- /6 SgAlt. Ph. I, {-k\e)40,4re, Go,yiez, , hereby state that the above information is current, true and correct to the best 61 my knowledge and agree to utilize my approved commissary in accordance with California Health & Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit revocation and pen. ties. Signature To be completed by COMMISSARY OWNER/OPERATOR r\ Commissary Name V•D\"\-Net")\-6,,c4. PR-ke et-A Address (Q2c) :;,.c-O,CcCA\NO.4\ s\-- Bus. Phon(206 )2-2.-k-i - )3-3 (-1 City Lct--:\ Zip qs- 2, LA Q Owner/Operator Piteiopoco, Cr,vi og Check all appropriate services provided: IF Wastewater disposal IS 3-compartment sink J. Electrical hook-ups Solid waste disposal 0 Food preparation A Toilet and handwashing Et Hot & Cold water for cleaning CI Store refrigerated food jil Potable water 0 Store dry food/supplies 1T Overnight parking IS, Vehicle wash I, COMM ,ssao-i 42)1 /4-e CO‘ , hereby state that the information I have provided is current, true and correct to the best of-lny knowledge, and meets the California Health & Safety Code requirements. If the food facility operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the commissary owner sh II notify the EHD immediately. Date 01 103/z y To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. The commissary is located in County. The above food facility meets the commissary requirements in California Health & Safety Code. The above checked services are available at the above commissary. Please notify EHD if the status of their operating permit changes. REHS Signature 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I vvww.sjgov.orgiehd PR Date 61163 1 20 FA# Signature Date