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SAN JOAQUIN <br />-COUNTY -- <br />Greatness grows her- <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 />1 To be completed by APPLICANT <br />Business Name L .- \ S -1-ActIJ x.CA Lic. Plate # D D <br />Owner/Operator Name 1.--kC e,-Or) &Oa\ <br />Business Mailing Address t b I 51 3c_flc Vcd I cy V L <br />City \i a Ovi eri qtretateLIAZip q5/-5(7._ Bus. Ph. Pq--(65.--7715 Alt. Ph.( 'c- 5 co --5Ccl <br />I, 1-.-tc)c-e_Mn , 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 an ties. <br /> Date Signatu <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name <br />Address 7s s--- ,4f6-d// 4,... <br />City teifil Zip 9'S;1(76 Owner/Operator <br />Check all appropriate services provided: <br />)31 Wastewater disposal /1:13-compartment sink <br />0 Solid waste disposal 0 Food preparation <br />,Ø Hot & Cold water for cleaning 0 Store refrigerated food <br />0 Store dry food/supplies ,EriOvernight parking <br />1, Xi/ , hereby state that the information I have provided is current, true and <br />correct to the be t 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 nob _the EHD 'mme ' tely. "....e/d <br />To be completed by the E M ALTH 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 />/ .ovil&/ t-a10 <br />Bus. Phone <br />FA# <br />27/, 9 7 <br />./M 62;15 /-74i9A/747 <br />grElectrical hook-ups <br />,Toilet and handwashing <br />J3'. Potable water <br />,'Vehicle wash <br />Signature -"e" Date 9-Y-02 / <br />000C11-