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SAN t-WOUIN Environmental Health Departmenk <br /> LAIIIIIIJ ---COUNTY---- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility* Caterer <br /> Complete sections I and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be.corn pleted-by APPLICANT <br /> Business Name LL 'k —I(� r -1 �T)I,-- . I <br /> Lic.Plate# S R 43, <br /> Owner/Operator Name N-drUILL28 MricJ L,--i n r' C,r <br /> Business Mailing Address <br /> �. i.nn <br /> city. State6,1-� Zip Bus. Ph :jAlt. Ph. <br /> ri <br /> I�-�v- J k 3 <br /> J <br /> hereby State that the above information is current,,true and correct to <br /> the best'-of my knowledge �aind 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 penalt'es <br /> Signature <br /> Dateav <br /> [2. Tobe coffipleited by COMMISSARY OWNERIOPERATOR <br /> Commissary Name L In FA# <br /> 4�1 15 <br /> Address �Acm-�'%V\.f4 ��&A Bus. Phone__00 <br /> City 0 C Y_kc.y-� Zip IS 'Z,:�15 Owner/Operator Q A '�n� <br /> Check all appropriate services provid ed: <br /> E3'*'W� astewater disposal 3-compartment sink 0 E4 trical hook-ups <br /> T�M"'Solid waste disposal M Food preparation Tallet and handwashing <br /> i6ot&Cold water for cleaning 0 Store refrigerated food Llp,_e ble water <br /> 0 Store dry food/supplies Ovemight parking :/Vehicle wash <br /> 1, J 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 notify the EHD immediately. <br /> Signature D <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 /> 9868 E. Hazelton Avenue i Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov-orglehd <br />