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. R S Q NJ(]Q Q N Environmental Health Department <br /> COUNTY <br /> c9c,pa? Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 9 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 h 0ti11 V'5 �?AlenhAf Lic. Plate# ?_P/(1 -/1 Y I <br /> Owner/Operator Name y/�p -;a <br /> Business Mailing Address 04fpeC-50h Sil <br /> City 54c/4 kA State CA Zip 02,06 Bus. Ph. Alt. Ph. <br /> I, Alec+ 6uadalx Barron , 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, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date ' <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name La Corni_wia AoA54v FA# <br /> Address 1211 S. _::�+` 5krte t. Bus. Phone 709'33$-36(03 <br /> City ,/�(c � Zip q5_5 51 Owner/Operator /t�fWf+ Zvi t—CA1:9 <br /> Check all appropriate services provided: <br /> p Wastewater disposal 13 3-compartment sink IO Electrical hook-ups <br /> p Solid waste disposal 0 Food preparation [3 Toilet and handwashing <br /> 0 Hot & Cold water for cleaning O Store refrigerated food 0 Potable water <br /> Store dry food/supplies 0 Overnight parking 10 Vehicle wash <br /> I, MGr h Lvis - Lry z- , 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 notif e EHD immediately. <br /> Signature %,/[ f Date <br /> 3. To 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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />