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_g;. <br />SAN JOAQUIN <br />— COUNTY----- <br />Environmental Health Department <br />ys here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility 4. 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 p to/ &.) <br />Owner/Operator Name -Iv p, k) Ci‘c---1)--\-e12-0 <br />Business Mailing Address (0 31(..,3 VE---(LY <br />City 00 bli State CfrZip 5 6KBus. Ph.! ]S Alt. Ph.2 <br />, hereb <br />the est of my knowledge y state that the above information is current, true and correct to <br />and agree to utilize my approved commissary in accordance with California Health & <br />Safety Code, and San Joa in County Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinue he permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />Signature Date 7fAp /62 0 al- c/ <br />To be compl ed by COMMISSARY OWNER/OPERATOR <br />Commissary Name I 0 10 Q. Pr NU( u( ( A# <br />Address 11 I] - OcOOk) .--i- Bus. Phone 2 Q) 2.... <br />City SIO(VCid ,U ZIP 9 SZoi, Owner/Operator 0 I k(-;'' /ULF 7;16406 <br />Check all appropriate services provided: <br />ttir Solid waste disposal .15 Food preparation <br />AY Wastewater disposal er 3-compartment sink <br />r Hot & Cold water for cleaning .5 Store refrigerated food <br /> AT Toilet and handwashing <br />.r/Potable water <br />Rt- Electrical hook-ups <br /> <br />Store dry food/supplies Et Overnight parking <br />%Vehicle wash <br />I, qe',5lIc4- c03 , 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 comp ,-Ionditions of this agreement, or if this agreement is modified or cancelled, the commissary ownioe EHD immediately. <br />Signature ( <br />To b ompleted 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 />C71 2Se0212 <br />Lic. Plate #'—IVX <-jr q 9 <br />Date i/CO t2-