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SANAAQUIN <br />COUNTY— <br />Greatness rows herp <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 />1. to be completed by APPLICANT <br />Business Name -TOr.4-, ( I r C Lc ftUpiccy-i 4 Lic. Plate # 1-1(4)) 6 .S9 9 <br />Owner/Operator Name (co ren NO,' ci cit E'-scit) LO <br />Business Mailing Address 3-7 i 2_ Fo pc..1 C— r <br />City SbckkrA State&R Zip cts 212_ Bus. Ph. Alt. Ph. <br />k ciii-e) r‘rncti-lciu LCIT1Zreby state that the above information is current, true and correct to <br />the best of my knowledge and agree to util ze 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 <br />12. lobe completed by COMMISSARY OWNER/OPERATOR <br />Date —2q)-2.5 <br /> <br />FA# <br />(2cc L t 7 0 <br />Commissary Name L-C., <br />Address 2_41 b cittN\ u:),c_k_ Bus. Phone <br />City sk)66c,--)-1 Zip CS 2US Owner/Operator G- V • <br />Check all appropriate services provided: <br />Wastewater disposal <br />lj Solid waste disposal <br />Hot & Cold water for cleaning <br />,21:1 3-compartment sink <br />Food preparation <br />Store refrigerated food <br />Electrical hook-ups <br />TiZt Toilet and handwashing <br />Potable water <br />o Store dry food/supplies , PI—Overnight parking fitVehicle wash <br />I, <br />1 <br />/I/4/4 TERN , 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 co 'a fions of this agreement, or if this agreement is modified or cancelled, the <br />commissa wshalInotifIther D immediatelpo <br />Signature - 4-sook- Date 13 -2--C <br /> <br />$. 1O 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 />fp.2.soo3(-1