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be corn <br />Business Name Lic. Plate # '171/4/L 7377 <br />SAN JOAQUIN <br />COUNTY <br />Grea tress grows here. <br />Environmental Health Department <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 />Owner/Operator Name a,“Akrt,ra-ti) (477, <br />Business Mailing Addressc;.V5 (1/70tA4.eJ 57 <br />City Rp: StateCh Zip 97V,61 Bus. Ph. 252_ 400-9154 Alt. Ph. <br />I, 4441404 / ND in eriiMitk_ , 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 />revocatior and penalties. <br />Signature <br />2„frQjbe completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name L-t."•A e I <br />Address )---9O 0 C a 5; Ac,r- 0-111 \'.\)Ck Bus. Phone ( 'WI - <br />City `Ao Zip q52,6S Owner/Operator G t2 t-2- <br />Check all appropriate services provided: <br />Wastewater disposal a 3-compartment sink El Electrical hook-ups <br />El Solid waste disposal 0 Food preparation Gt Toilet and handwashing <br />r:kHot & Cold water for cleaning 0 Store refrigerated food tiz Potable water <br />0 St re dry food/supplies 0 Overnight parking 10 Vehicle wash <br />( / /—zi.009/tdi , 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 th conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary o ner shall notif4 e EHD im diately. <br />Signature Date oif <br />Tabe 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 />.17)R 00'2-g <br />me Gelm,i Date <br />FA# <br />L S"