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I 1 14. R49,0, <br />, 4r..•=0•11r <br />S. <br />SANAAQUIN <br />—COUNTY- <br />Greatness grows here. <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility S. 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 />odd Gri ilLic. Plate # V5-7 C/S7r- Business Name Ike. <br />Owner/Operator Name '011-(MA K1 laecob Powei <br />Business Mailing Address <br />City l.Ailik)/ (-5-C4 State Zip qs--3 47 Bus. Ph. ()W - 44L-P-i --;726Alt. Ph. <br />0 AL(L., . po ,Are-,4,1.. , 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, a n Joa n e ty Environ me ealth Department (EHD) requirements. If the use of the <br />commissary disco tin d, t perm' hold,flln t noti the EHD. Failure to notify this office may result in permit <br />revocation <br />Signature Date ) o <br />J <br />;,34210c)i(-7 <br /> <br />2. To be comp eted by COMMISSARY OWNER/OPERATOR <br />Commissary Name U/Ui 0A) eiU1AJ c7 -7 .4(-4 -- CEN7(.7KA# <br />Address [7I -) - CI )0 3/ Bus. Phone <br />City 5-10eCt(Pk) Zip CI cD, 0 cc-7 Owner/Operator 0,-51 e,C A} ,eA-10?) <br />Check all appropriate services provided: <br />X Wastewater disposal <br /> LI 3-compartment sink <br /> <br />Electrical hook-ups <br />Solid waste disposal <br /> LI Food preparation <br /> <br />'I$ Toilet and handwashing <br />Hot & Cold water for cleaning Store refrigerated food ,K Potable water <br />,Store dry food/su plies <br /> ri Overnight parking <br /> < Vehicle wash <br />i/KA , hereby state that the information I have provided is current, true and <br />corr t to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to compl e conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary ow the EHD immediately. <br />Signature Date <br />3. To e completed 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 Stockton, California 95205 T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />7-7R.25 00