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SANAMUIN Environmental Health Department <br /> S>< �, —COUNTY— <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 /> 1.Tobe:000letedti APPLICANT` i <br /> Business Name 1CA Yi 15 C VI I n P5 e Food Lic.Plate# Ll IN "1 G Ll(:p <br /> Owner/Operator Name knnti '0) <br /> Business Mailing Address S L <br /> City S h State Zip 2 Bus. h. AIL Ph. Z� �! 7 j�� q <br /> f hereby state that the above information is current,true and correct to <br /> the best of rhy knowledge and agree to utilize my approved commissary in accordance with Caliifomia 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'ties.� � Date <br /> SignatureQLAAA— <br /> 2 To be=cofn Idted;b .: MMISSARY-OWNER/OPERATOR �- <br /> Commissary Name LA Cn OAe C_% !A\ FA# <br /> Address f Bus. Phone aoG• /1L� <br /> City. tc.�un Zip_ � 15 Owner/Operator Oni n Acne_- -t <br /> Check all appropriate services provided: // <br /> (Wastewater disposal IQ 3 comparbnent sink Fd E110chical hook ups <br /> e5olid waste disposal 13 Food preparation T 'let and handwashing <br /> @ Hot&Cold water for cleaning ® St refrigerated food � ble water <br /> €i Store dry food/supplies Ovemight parking Vehicle wash <br /> I, , Si (_Ct )0 C'Q2 hereby state that the information I have provided is current,true and <br /> correct to the best of my k o edge,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 own" ll notify t 131 miAstely. <br /> Signature Date I Z ^ 119 <br /> 3. To e . [n d by-the ENV HEALTH 'urisdiction outside of,San':Joa din 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,Califomia 952051 T 209 468.34201 F 209 464-0138 1 www4gov orgfehd <br />