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SAN JOAQUIN Environmental Health Department <br /> --COUNTY-- <br /> Ireet ,<s ro , irre. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facilitya 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 completed by APPLICANT <br /> Business Name ` I`LLA✓tt�. (P <br /> e Llr-Q� Lic. Plate# 11 2—+ ,,s <br /> Owner/Operator Name AzywindeAnfO LAu,z <br /> Business Mailing Address ifl"1 \ Ask-We..0- C+ <br /> CitySSt"ate a4 Zip__'153XBus. Ph.(M) 161-32-4"3 Alt. Ph. <br /> I, YYl�yn�P n t4 /w�uy 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' �./Al.�.�e1� Date i 2A �l <br /> 2. To be completed.by COMMISSARY OWNER/OPERATOR <br /> Commissary Name i L\( (V 0 9 C£ CRL P f"I FA# <br /> Address 3y ,,:l, E. Bus. Phone <br /> City S%a C YC Tv W Zip CA ok Seo -S Owner/Operator <br /> W <br /> Check all appropriate services provided: p x <br /> ® Wastewater disposal 1 3-compartment sink Electrical hook-ups m Z <br /> ;Solid waste disposal % Food preparation Toilet and handwashing p <br /> U ;Hot & Cold water for cleaning a Store refrigerated footle a Potable water Z Z n <br /> C) mm <br /> 'Store dry food/supplies Overnight parking ? Vehicle wash y <br /> I, hereby state that the information I have provided is current, true and N 4e <br /> correct to the best of my knowledge, and meets the California Health &Safety Code requirements. If the food facility N r11 m <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 cC,7f:y) ,,., Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin Go. <br /> The commissary is located in County. The above food facilitymeets 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 I F 209 464-0138 1 www.sjgay.org/ehd <br />