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'SAN JOAQUIN <br />— COUNTY - <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility f• Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />To be completed by APPLICANT <br />Business Name / / rIt\gi 31 Lic. Plate # p f •-r• <br />Owner/Operator Name jorMn -146)Alcirdi(VA <br />Business Mailing Address 1-*)-{-c-(4 6uci 5pc <br />City "l000-Aeco Statein Zip GIce_i.F.,-736 Bus. Ph. (2er-01 Alt. Ph. <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 (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 and pena,ties. <br />Signature <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name C K rV Gc c ro,ecn <br /> <br />FA# <br />flJj 0) <br /> <br />Address .3(11:.), 0-3; rvER Bus. Phone <br />City -S1 '70 C i-)/ Zip c-,A) Owket‹);erator <br />Check all appropriate services provided: <br /> <br />Wastewater disposal 0 3-compartment sink <br />C) Solid waste disposal CI Food preparation <br />0 Hot & Cold water for cleaning s'"---13 Store refrigerated food <br />0 Store dry food/supplies —12-,Overnight parking <br /> <br />Electrical hook-ups <br />Toilet and handwashing <br />0 Potable water <br />El Vehicle wash <br /> hereby state that the information I have provided is current, true andt0 To x <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility 2 r" 5, M <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the° !" > <br />Cra C commissary owner shall notify the EHD immediately. <br />Signature Cr-:‘:-,------ C-7,---24-1 <br />To be 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 I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />/5002-1 (40 <br />Date <br /> <br />Date /- 29