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SAN JOAQUIN <br />--COU NTY- <br />reitrecs 9row .1(= <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 />APPLICANT <br />Business Name na Ofyl, n (1 V \c It Q Lic. Plate <br />L1ki Cl I I Li <br />Owner/Operator Name ''\; tf-,111(1 V-trLClio CI e <br />Business Mailing Address 2_ ,rbnc,y-CA <br />City .)*6 StateC IA. Zip 95-2(.',c, Bus. Ph. )-V ci (S) 37 Ph. <br />E v e- < z. c'700.,ZhceltUATate 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 vironmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinued, the permi older must notify the EHD. Failure to notify this office may result in permit <br />revocation an ies. <br />Signature <br />Wife** COMMISSARY OWNER/OPERATOR <br />Commissary Name L-C.. Ccn.e,r CA. CAA FA# <br />Address 2 c't0 "a • - ¼'r ( Uk.i Bus. Phone 20 9- Li (pH — LIS-70 <br />City Sk.c.;.c.I.O.kel Zip 9 5-L0 S Owner/Operator C71 —0A-Op " Pre <br />Check all appropriate services provided: <br />ZE(Wastewater disposal <br /> jt 3-compartment sink <br /> <br />g Electrical hook-ups <br />AKSolid waste disposal <br /> <br />O Food preparation <br /> IEKToilet and handwashing <br />& Cold water for cleaning <br /> O Store refrigerated food <br /> <br />a Potable water <br />0 Store dry food/supplies <br /> Z.Overnight parking <br /> rs,- Vehicle wash <br />, 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 owner sh19notify the EHD immediately. <br />Signature <br />Date <br />• <br />Date <br /> /0! <br />.:4-kftira . <br /> <br />IkAivitby the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> <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.orgiehd <br />Pk190012-1