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SAN JOAQUIN Environmental Health Department <br /> —COUNTY--- <br /> COMMISSARY <br /> OUNTy—•-COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete sections 1 and 2. if your commissarlf is located outside of San Joaquin Count*;also complete section 3. <br /> -1. To be Completed by APPLICANT <br /> Business Name L ' :LCL ' Lic. Plate# <br /> Owner/Operator Name l t zl— L �z °&a - <br /> Business Mailing Address <br /> City( llk/&11z Slate/*Zio /� ✓� Bus. Ph %TII'Alt. Ph. <br /> 1,�—����1 f��� k('P.&a e) hereby state that the above information is current,true-and co}reci to <br /> the bdst of my kndiliedge and agree to utili?e my approved commissanj 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 penal"ies. <br /> Signature Date 2-12., � _0 2I,. To be completed by WMMISSARY O NER/OPERATOR _•° <br /> (�jVCommissary Name CC � FA# <br /> Address A u) Bus. Phone ,Abe- �/Lt�� � � 17Z <br /> City c I I tekt L ?ip q!,L-2 0 Owne 1Operaior J. <br /> Check all appropriate services provided: V <br /> I-Afastewater disposal 3-compartment sink X Electrical hoof;-ups <br /> Solid waste disposal Food preparation K Toilet and handwashing <br /> X Hot& Cold water for cleaning _ Store refrigerated food 9 Potable water <br /> WT <br /> dry food/sup lies Overnight parking i Vehicle wash <br /> I, /t1W_/1: FkhA11/d t 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,4ortditions of is agree ent, or if this agreement is modified or cancelled, the <br /> CO, missaryp/wershal�.not .EHD imrne artily. %.. � <br /> Signature G ' J�/U 6 , Date JA e <br /> 3. To be completed by the ENDO HEALTHjurisdiction outside of Sao 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 /> P.EHS Signature Date <br /> 868 E. Hazeitor Avenue 1 Stockton,California 952051 T 209 466-34.201 F 209 464-0133 1 vrtf,rw.sjgov_oq lend <br />