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�- SANAMU1N Environmental Health Department <br /> —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 To be:COni feted b - APPLICANT 7/ <br /> Business Nameaz A7(/n- 2)(11 cLie.Plate <br /> Owner/Operator Name :; rno/I r'7JPi _a <br /> Business Mailing Address L/ <br /> ��v/ <br /> city C/0C44C7!: .. . State Zip Bus. Ph.=?,g516-07S -Alt. Ph. <br /> I, 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 /> / �. <br /> Signature orf /; >r%/l: . Date�L L L� -L O L <br /> 2�To be bbmp le-teitt '"_COMMISSARY OWNER/OPERATOR <br /> CommissaryName LA C-(,)MQx c k („\ FA# <br /> Address aIlOO E "(nrfr A"A WQ�n Bus. Phone 24C)CI• j-1 1_1 X15 70 <br /> City 0k0r Zip 01S 22o Owner/Operator <br /> Check all appropriate services provided <br /> j"Wastewater disposal Er 3-compartment sink 0 EI ncal hook-ups <br /> /olid waste disposal I3 Food preparation �T 'let and handwashing <br /> E Hot&Cold water for cleaning © Sto a refrigerated food iH P able water <br /> 13 cStorre�dr food/supplies Overnight parking Vehicle wash <br /> I,1500y-f- . 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 tic comp) with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary o�ihe sh I not'fy the EHD immediately. / <br /> Signature �I �� Date <br /> 3 Cote coM. leted.:b ,the ENV HEALTH jurisdiction outside,ofiSan.;Joa uin.Go. : <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 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov_oralehd <br />