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SAN JOAQUIN <br />, —COUNTY <br />cs dAS:tot-s," Greatness grov%, her <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 t4k sWEE'T Lic. Plate # <br />Owner/Operator Name =CAL tAE L-oeEz <br />Business Mailing Address tazo DE ovel3 AVa • <br />City STcc.v.vc., State cA Zipi9S 20+ Bus. Ph.(209) 5c) -5511-Alt. Ph. <br />I, 3-AIME Lo PE 2.. , 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 />os / to I 24, <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name SToc._T-ot.. co DA t•40t4 tT‘e KATC..i-kE FA# <br />Address tto t•li -EL Do a&C.c) *ct- Bus. Phone <br />City S-TOC. KL/D 1,1 Zip 9520a Owner/Operator LECet.L.E1.. CAS-T1L-LO o Fo LYDET2 <br />Check all appropriate services provided: <br />El Wastewater disposal <br />Et Solid waste disposal <br />a Hot & Cold water for cleaning <br />gi Store dry food/supplies <br />I, t...E0t-LEL CAST t LA-0 <br />Er 3-compartment sink )3. Electrical hook-ups <br />Food preparation ,Ef Toilet and handwashing <br />Store refrigerated food fl Potable water <br />Ove•Fnigl-rt parking 0-Veli4ete-Yeas19-- <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 />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary 9)thj shall notify th EHD immediately. <br />Signature Date <br /> <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 />241 ON <br />Date