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SAS! JOAQUIN Environmental Health Department <br /> ----COUNT Y <br /> 153 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 L./.'a.,a �GbC;ti Lic. Plate# Ay q q S ZI�). <br /> Owner/Operator Name Toch du=,, Zp 11 <br /> business Mailing Address 12 2S S a4 t As <br /> City ROO&4A State CA Zip AL-1 Bus. Ph._— y2s V7- Alt. Ph. <br /> rr-le.rci4 ,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 pe (ties/.. / /f <br /> Signature ! �/ Date <br /> 2. To becorrioletedby COMMISSARY OWNER/OPERATOR / <br /> Commissary Name L6 6.j54,,-4 9&4549 FA# <br /> Address (?-It S• 7- . 4-me* Bus. Phone 209- 33'5 -3 6 G 3 <br /> City /�(o�sao Zip 45351 Owner/Operator�Qld . 14C <br /> Check all appropriate services provided: <br /> 'Wastewater disposal 11-3-compartment sink IT-Electrical hook-ups <br /> i-Solid waste disposal 0"Food preparation C'Toilet and handwashing <br /> IrHot&Cold water for cleaning C' -Store refrigerated food C'Potable water <br /> arstore dry food/supplies ❑ Overnight parking dVehicle wash <br /> I, 1(4,sr k l u is-iifr%oz , hereby state that the information I have provided is current,true and <br /> correctto 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_4 � Date <br /> 3. To completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in !6k1-I I (I d u S 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 il Date `//02( /aDo"� <br /> U �J J 9,42Q.np-ffi , 2E91 <br /> 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />