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SANAAQUIN <br />--COUNTY <br />Gaatrtess grows ht?,e, <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility 44 Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />th ód by APPLICANT <br />Business Name Tcc s 0 10 Nrt o Lic. Plate # 5 -5 (el 1,9 ti 2. <br /> <br />Owner/Operator Name Pun-4-C.4. (-1 c-tbrer-CA e--L at.) d c nr-io <br />Business Mailing Address —I (0 ç 4;tccri e_12, <br />City 9-0Cilk-o,\ State en. Zipq 0 Bus. Ph. 10i 37S 65241t. Ph. (-16( LO 9 5- 90'1? <br />e.ct khi-e ‘r-C , , 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,Lepermit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />Signature <br />4f <br />eorhbleted by COMMISSARY OWNER/OPERATOR <br />Commissary Name L-Ck CONC0 e‘rCL Ct• Q0Cp FA# <br />Address 2-ci 0 0 VC,1/4-‘r (Am, w cl Bus. Phone 70 9 <br />City SI-C-1-1-(4-un Zip 9. 5 2 i) (4) Owner/Operator C-1 E a (kip n_{-1- <br />Check all appropriate services provided: <br />jzt Wastewater disposal <br /> cu. 3-compartment sink (KElectrical hook-ups <br />tErSolid waste disposal <br /> O Food preparation 113:Toilet and handwashing <br />JHot & Cold water for cleaning <br /> O Store refrigerated food <br /> <br />12LPotable water <br />0 Store dry food/supplies crkOvernight parking <br /> CiEtVehicle wash <br />It2 Ct r CQ n_t, ç , 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 owner shall otify the EHD immediately. <br />Signature <br /> <br />Date <br /> <br />Ibleted by the ENV HEALTH jurisdiction outside of San JoaqUin <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 />W15 DIOS <br /> <br />Date <br /> <br />go- Liczo