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rN 1. To be completed by APPLICANT <br />Business Name 1/1//11 Lic. Plate # <br />Owner/Operator Name16.0."0/7 <br />Business Mailing Address e3e, (ohh/erzcive re)z&*7 <br />City ///i StateCA Zip Bus. Ph9 V.s-7/eAlt. Ph. <br />I, Jo Sep 17 (.___.'"e1"7 , 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 penal <br />Signature <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Date <br />r...ce Us tv <br />(-; <br />L.. <br />)r- os.234\ <br />SAN JOAQUIN <br />—COUNTY <br />Greatness grows here. <br />PR 25002 (10 5 <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 />Commissary Name <br />Address 2-1 5 S <br />s-1/140e,C). City Zip <br />Check all appropriate services provided: <br />FA# <br />Bus. Phone <br /> <br />(Lo( <br />Owner/Operator <br />Wastewater disposal <br /> <br />O 3-compartment sink <br /> <br />O Electrical hook-ups <br />1:1 Solid waste disposal <br /> <br />O Food preparation <br /> O Toilet and handwashing <br />Hot & Cold water for cleaning <br /> O Store refrigerated food <br /> <br />O Potable water <br />Store dry food/supplies <br /> O Overnight parking <br /> O 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 />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled e <br />commissary owner shall notify the EHD immediately. }LA_ <br />Signature k77-N"cf ke-1..tAC C—Date <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 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 />g14,1 (Om4 1_7 ,„