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SAN JOAQUIN Environmental Health Department <br />—COUNTY <br />Greatness grows <br /> <br />COMMISSARY AGREEMENT <br />Mobile Food Facility 4' 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 -TA Ues:3 L -"It; IV, C' Pt- 2- <br />Owner/Operator Name M y y I o 5 j2 Ak Tie <br />Business Mailing Address tA <br />City 5-11)C410 StateC4 Zip (TS-A (:) Bus. Ph. 5/' -2.5q --),(c2g Alt. Ph. <br />I, iC10 3 IAA . , 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 pen <br />Signature <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name U A..) iC /U Cijc--/C/ 7/Z(/(/C CL-7 /Vic-eFA# <br />Address 11 ) )J 10 /0 Bus. Phone 2 0::1 - 2- L:)(() <br /> <br />City .S1OCK,-70 •'') Zip cc)-() G7 Owner/Operator R.0 /UT 7/ C4 <br />Check all appropriate services provided: <br />j3. Wastewater disposal <br />pi Solid waste disposal <br />Hot & Cold water for cleaning <br />0 Store dry food/supplies <br />I, \A , hereby state that the information I have provided is current, true and <br />correct to the best of my knowledte, and meets the California Health & Safety Code requirements. If the food facility <br />commissary own- r • . • s, 7ieEHD immediately. <br />operator fails to comply with af conditions of this agreement, or if this agreement is modified or cancelled, the <br />Signature V - ' <br />.,„ zol„, .. .,47/ - <br /> 7 II <br /> <br />Date ( 1 1)-1 t)0,2(--/ <br />, <br />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 I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />"?R2.5 OD 'Z3- <br />Lic. Plate # e K6; <br />Date <br />3-compartment sink Electrical hook-ups <br />Food preparation y Toilet and handwashing <br />Store refrigerated food < Potable water <br />Overnight parking Vehicle wash