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SAN0JOAQUIN <br />—COUNTY-- <br />.17 <br />at - <br />ev- 71. 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 />I 1 TO' beEcompleted= by APPLICANT <br />Business Name <br />Owner/Operator Name <br />Lic. Plate #44 \IS1 Wi <br /> <br />Business Mailing Address 1_1, 5A- C cityrnocke,40 stateep- Zip C15351 Bus. P hODODC-f 1(0-- ?StiOYAlt. Ph. <br />1, C'(6 7-7q(4e& oci;h ez, , 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 obilite2 Date /0 I ),5 <br /> <br />1 2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name n-')CY1(-Jr\Kilfd 01 i 610Ci,:-.S. FA# Oleg oi <br />Address Q4-i5 N 9con 0 B us. .s Lti 7 - <br />Phone eos) 5c0.--1 1 -10 CityLOS W‘nos Zip 015(Dgc Owner/Operator c-.X),.{11-(.,1 ItY)C1Y-b.yleT"_ <br />Check all appropriate services provided: <br />0 Wastewater disposal 4 3-compartment sink 0 Electrical hook-ups ,it., kil Solid waste disposal F , <br />vu. Food preparation 0 Toilet and handwashing <br />, Hot & Cold water for cleaning V Store refrigerated food 0 Potable water <br />ir71 Store dry food/supplies 10 Overnight parking 0 Vehicle wash <br />I, atrk M104 -1t- (ler- , 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 own hall notify the EHD immediately. <br />Signature <br />3. To bezompleted by the ENV HEALTH jurisdiction outside of San JoaquinCo. I <br />The commissary is located in <br />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.orgiehd <br />Date t1 <br />Copy <br />25-()D2"11