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r‘ <br />SAN JOAQUIN <br />—C OUNTY-- <br />Gri,gioe $s grow; <br />Environmental Health Departmeni <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 />To be completed by APPLICANT <br />Business Name e foi Lic. Plate # <br />Owner/Operator Name ri 15\ .C C-1}4 e CO <br />Business Mailing Address (0 31 Lk) <br />City Co bli State Gip (--1 5 (9KBus. S-S- Alt. Ph.2 O cl- 69(0 -RsS9 1,10A e oihm(-)7,0 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 Joa in County Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinue , e permit holder must notify the END. Failure to notify this office may result in permit revocation and penalties. <br />Signature <br />To be compk ed by COMMISSARY OWNER/OPERATOR <br />Check all appropriate services provided: <br />Address 1111 - OculOk) fl. Bus. Phone z ()CO 2_9 07° <br />City _1()C,(C 7 zip 95-219C, Owner/Operator <br />Commissary Name k) Or'.) Piielitki vocr( Ce-/viertA# <br />031 1116 7e4oO <br />Wastewater disposal 1c3-compartment sink <br />Electrical hook-ups <br />Solid waste disposal N- Food preparation <br />Toilet and handwashing <br />( Hot & Cold water for cleaning S Store refrigerated food K Potable water <br /><-- Store dry food/supplies <br />Overnight parking <br />)(Vehicle wash <br />Signature owr(10 <br />e <br />commissary <br />operator fails to comp nditions of this agreement, or if this agreement is modified or cancelled, the <br />correct o the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />EHD immediately. <br />, hereby state that the information I have provided is current, true and <br />Date <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />To b ompleted by the ENV HEALTH jurisdiction outside of San Joaquin Co. I <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 />REHS Signature <br />Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 l F 209 464-0138 www.sjgov.orgiehd <br />Date <br />03 IA