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SAN,JOAQUIN <br />COUNTY— <br />Greatness grows here <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 Et -p,4_,,grufc, IDS r lki Lic. Plate # w,T9 9 93 <br />Owner/Operator Name ?airy) t 7—ld 1. vi1C1ocx7 <br />Business Mailing Address 107 ¶ µtit_s fl-ue <br />City LLYY‘ StateCP Zip ci521.1 2- Bus. Ph. (-20c,)42-6(42 ' Alt. Ph(.20q):310-2c404 <br />I, Vvyr-h, lo A-k-ernirdeZ , 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 [2c 'AC/ (6 <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Co mfil t.5Scir i E / 6 q 1/19 -rix- _ FA# ze 5 -33//- PS 0 <br />Address 35, A) . Gcktici Ac.. Bus. Phone 2 (2 1 • 1 -9- ZS 73 <br />City Lc) d t' Zip ci 7. ii 0 Owner/OperatorA I be (A-cf) AJ of ? u e z_ <br />Check all appropriate services provided: <br />IIWastewater disposal pi 3-compartment sink etfElectrical hook-ups <br />11-Solid waste disposal 0 Food preparation kToilet and handwashing <br />..17c Hot & Cold water for cleaning 0 Store refrigerated food KECPotable water <br />0 Store dry food/supplies jiOvernight parking 12CVehicle wash <br />I, A16.1 It) AloqUer , 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 the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall j the E immediately. <br />Signature Date 2 - / 7_ 7oz5 <br />3 To be completed by theJV HEALTI-1 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 />RENS 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 />QD <br /> <br />RulL <br /> <br />Date 01 72:Z /2_ OZ5 <br />