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*--Ircscl,SANJOAQUIN <br />COUNTY <br />Greatness grows here <br />11 tWg, <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 />To be completed by APPLICANT <br />Business Name <br /> <br />G skt•ICI1A- ICc.. <br /> <br />Lic. Plate # ItS <br /> <br />Owner/Operator Name Eibig_N t kwd_ clor-m <br />Business Mailing Address (ctz_ cke_ <br />City Lcok <br /> <br />State Zip ctc.2AL, Bus. Ph. 261---iiik-d62)( Alt. Ph. <br /> <br />I , eik),40ANNW;1-- t.3. , 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 penalties. <br />Signature 1141l fir c1- Date <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name <br />Address 1-11'), E ker Ow) <br />City c4-1, .1-r..r. \ Zip qs2..oc- Owner/Operator Sa.VWCONV Ec,I,t, ‘, <br />Check all appropriate services provided: <br />g Wastewater disposal 0 3-compartment sink M.-Electrical hook-ups 0 32 <br />-4 Ce 0 <br />'Solid waste disposal 0 Food preparation II-Toilet and handwashiQ :I X <br />0 i%) <br />W-Hot & Cold water for cleaning 0 Store refrigerated food 0 Potable water X <br />4 <br />m <br />-1 • G) <br />0 Store dry food/supplies tit Overnight parking 0 Vehicle wash 0 g 0 <br />Z — <br />I, CArrk rr \ C Cn'. , hereby state that the information I have provided is current, tri/a a —05 <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food i M <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelle t 0 <br />X <br />cn 4c rn <br />Signature Date \ P)tf 15 O' PI > cn c <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.org/ehd <br />‘1-3 11-5 <br />FA# <br />Bus. Phone <br />commissary owner shall notify the EHD immediately.