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t SAN J OAQ U I N Environmental Health Department <br /> COUNTY <br /> �r <br /> Greatness <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 ccmplete section 3. <br /> 1. To be completed by APPLICANT <br /> Business Name '4 L�-'L/� Lic. Plate# <br /> Owner/Operator Name I AVtZ' )90 6_)_ r/' Lo Q <br /> Business Mailing Address -7 3y 1,& C4"_1 71�,it✓ <br /> City 4,�)<. P L L State�Zip G/���� Bus. Ph 2 7 yG 216 _-__Alt. Ph. <br /> �'I i- <br /> 1, <br /> ' <br /> I, 7ALkTIr) T-r IA!'ry 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 Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name L4 Coh►%Sa►-;a Aodes ly FA# <br /> Address /7 11 5, +" 5 -re-e-4- Bus. Phone 2_04 -35 f-36 63 <br /> city AodZ-'s ky Zip q5,3 5 Owner/Operator-61d S� C ' , lkc. <br /> Check all appropriate services provided: <br /> Wastewater disposal 3-compartment sink O'Electrical hook-ups <br /> 'Solid waste disposal - Food preparation Toilet and handwashing <br /> d Hot & Cold water for cleaning -Store refrigerated food 0,Potable water <br /> Store dry food/supplies ' Overnight parking &: Vehicle wash <br /> I, Xork L vi 5-6n't , 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 Date <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 /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />