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Date commissary owner shall not the E1J immede Signature efl -K SAN JOAQUIN Environmental Health Department --COUNTY-- • COMMISSARY AGREEMENT Mobile Food Facility. Caterer Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. To be completed by APPLICANT Business Name AC OW 0%. GI (..ceSSiQ% 11--v\_C Lic. Plate # 3 61S St Owner/Operator Name Business Mailing Address 33:1 E P\A(Afkvi, kV SS City (-1-t kkon State C4 Zip IS lia-S Bus. Ph.Sio - Y83-193i Alt. Ph. I, &CI C•A Co.,SS 'I kr", lzk 1 "S. , hereby state that the above information is current, true and correct to the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit revocation and ti Signature To be completed by COMMISSARY OWNER/OPERATOR Commissary Name •-11 A FA# Address L70/ r licroiy,,74 ,fif--- Bus. Phone):"Ofii 35 y-- 2s--;2? City Zip 952n Owner/Operator //RA t-74/p/e? 6g4 Check all appropriate services provided: Wastewater disposal T(' 3-compartment sink pICElectrical hook-ups )1, Solid waste disposal 0 Food preparation et Toilet and handwashing pir Hot & Cold water for cleaning 0 Store refrigerated food FPotable water 0 Store dry food/supp,lies rkOvernight parking Or-Vehicle wash I, 414/ kt k. , hereby state that the information I have provided is current, true and correct to the est of my knowledge, nd meets the California Health & Safety Code requirements. If the food facility operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the To be completed by the ENV pIP TH jurisdiction outside of San Joaquin Co. The commissary is located in County. The above food facility meets the commissary requirements in California Health & Safety Code. The above checked services are available at the above commissary. Please notify EHD if the status of their operating permit changes. RENS Signature Date Date 1868 E. Hazelton Avenue Stockton, California 95205 T 209 468-3420 F 209 464-0138 I www.sjgov.org/end