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SAN .J OAO U IN Environmental Health Department <br /> 1 . --CoUf i-F <br /> COMMISSAR" 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 /> ' <br /> lb be completed by APPLICANT <br /> Business Name L(V� -M N� 9 6D 5 Lic. Plate# <br /> Owner/Operator Name IR LA <br /> Business Mailing Address2, L <br /> q 0 � LQ <br /> Cit ��' State Zip�Bus. Ph.���j � Zo�Alt. Ph. <br /> I, a , hereby state that the above information is current,true and correct to <br /> the best of my knowled e 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 Date <br /> . To be completedb V COMMISSARY Q:WNER/OPERATOR <br /> Commissary Namet m-fyfu; O fa T .1� <br /> Addres l,�o Yl lA, SV - Bus. Phone 2 <br /> City Zip * Owner/Operatortfldp� <br /> Check all appropriate services provided: �- <br /> c/Vastewater disposal C "3-compartment sink LYElectrical hook-ups <br /> �o'd waste disposal EYF od preparation �ilet and handwashing <br /> Hot & Cold water for cleaning 0 S re refrigerated food Po le water <br /> 0 St re dry ph <br /> es od/sup es Overnight parking O'Vehicle wash <br /> I l , hereby state that the information I have provided is current,true and <br /> correc o the best of my nowledge,and meets the California Health &Safety Code requirements. If the food facility <br /> operator falls to c mplyw' h the conditions of this agreement, or if this agreement is modif'ed or cancelled, the <br /> commissa o ner shall nl ify the immediately. . t <br /> � � I q <br /> Signature W-�A AIA rAIVO Date <br /> 1 — <br /> j 3. To be completed.by the ENV HEALTH..jurisdiction outside of Sari Joaquin Co.1 <br /> The commissary is located in County. The abovee 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 /> RENS Signature Date <br /> 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 wwvv.sjgov.org/ehd <br />