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SANJOAQUIN Environmental Health Department <br /> Gq <br /> —COUNTY- <br /> 4"'a Greatness grows here, <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 /> 9 . To-be_CompletelId byT <br /> - -APPLICANtom/ ? <br /> Business Name- LCL Cly 51 L r Lic. Plate# dy7 <br /> I ► $ �1 <br /> Owner/Operator Name Nor-0, ze4d � <br /> Business Mailing Address (i5 N &Z . r`ylai - n <br /> ere. <br /> CityS�OG�turl I StateCA Zip S�(Bus. Ph` 09 ` 6 Z2t- Alt. Ph. <br /> I, Nara _Z ed CA , 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 AIOi74 Date Q Ir Z4 <br /> 2. To be 6ornl5leted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name ' FA#� �J 3 � <br /> Address Bus. Phone 5dW _Z7 4 - 72 <br /> City - Zip4�c)Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal 13 3-compartment sink Electrical hook-ups <br /> WSolid waste disposal O Food preparation ( Toilet and handwashing <br /> WHot & Cold water for cleaning O Store refrigerated food 5YPotable water <br /> E3 Store dry food/supplilies IWOvernight parking vehicle wash <br /> I, hereby state that the information I have provided is current,true and <br /> correct to the best of my kn Gledge,and meets the California Health &Safety Code requirements. If the food facility <br /> operator fails to comply ith the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall tify the HD ' iately. <br /> SignatureDate -��� <br /> 3. To be completed by the E49 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 />