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1.10 be completed by APPLICANT <br />Business Mailing Address co2 paciFic aVe_ <br />City STUz- kv\ State C4 Zip 47f2 0-- Bus. Ph. &3 4) 66 Alt. Pn. <br /> , hereby state that the above information is current, true and correct tf.- <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 penaltiez. <br />C4 I ic•-' Date / ,3ignature <br />I 2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 1 Ccr 4., (& p1j FA# <br />Address 2 /)o s A- k 4- EA ,c4..j Bus. Phone 2-0 1— ç I— <br />City C LCk-,--A zip 9 clt. Owner/Operator eS <br />Check all appropriate services providea. <br />It 3-compartment sink <br /> cr Electrical hook-ups <br />Food preparation <br /> trToilet and handwashing <br />it] Store refrigerated food <br /> Potable water <br />Overnight parking <br /> Cr 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 />)perator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall notify the EHD immediately. <br />Signature <br /> <br />Date <br /> <br />131 Wastewater disposal <br />Solid waste disposal <br />ESI Hot & Cold water for cleaning <br />XI Store dry food/supplies <br />i• 70— Ldlot <br />Owner/Operator Name tclidi <br />erl ,z-ro <br />(:,il- // 0 /1 <br />Lic. Plate # r q 3 Business Name Tato <br />Environmental Health Department <br />COUNTY— <br />, Grecitness circ,ws here. <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 <br />3. 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 Da-E <br />158 E. Hazelton Avenue I Stockton. California 95205 I T 209 468-3420 I F 209 464-0138 I www.sigov.org/ehd <br />\-)g 2502-911 <br />fy"