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SAN J 0 AQ U I N 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 completed by APPLICANT <br /> Business Name The Lemon Box Lic. Plate# 4RZ9085 <br /> Owner/Operator Name Nicole Moore - Raygoza <br /> Buskess Mailing Address 478 Providence street <br /> City MT. House State CPzip 95391 Bus. Ph. 510-589-6166 Alt. Ph. <br /> I, Nicole Moore - RaVgoza , 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 anhRV-tM0)� <br /> Signature ll��u�//CC�A Date 04-20-2021 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name —r —N FA# JA <br /> Address 3LZ 1 �Dny Bus. Phone 201 - K�I — (9.331 <br /> City\`-aL4 Zip C) Owner/O ep rator I"mac C L_ <br /> Check all appropriate services provided: <br /> ® Wastewater disposal ❑ 3-compartment sink ❑ Electrical hook-ups <br /> ❑ Solid waste disposal ❑ Food preparation [3 Toilet and handwashing <br /> ❑ Hot & Cold water for cleaning ❑ Store refrigerated food ❑ Potable water <br /> ❑ Store dry food/supplies ❑ Overnight parking ❑ Vehicle wash <br /> I, : 1 Lha—( % , hereby state that the information I have provided is current, true and <br /> correct to the best of my knowlbdge, 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 noti D immediately. <br /> Signature c _ Date Z112a�7_,oZ—i <br /> 3. To be completed by the ENV 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 />