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$AN,.IUANIN Environmental Health Department <br /> —COUNTY-- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 4 Caterer <br /> Complete sections 1 and 2. !f your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be com leted by APPLICANT <br /> Business Name Lic.Plate# '1/ 1>Q8 ;7 <br /> Owner/Operator Name �a�✓la D� �L <br /> Business Mailing Address �' j yL'_ 'J/ d'�" <br /> City_�JP // State�4 Zipys/�� Bus. Ph.�59-Gle-v77' Nt Ph. 55'9 <br /> I, M Q..V Na �7P g Q��,hereby state that the above information is current_true and correct to <br /> the best f 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 /> SignaturePei%n2 ervr <br /> ,f4- T Date <br /> 2 To be completed b COMMISSARY OWNER/OPERATOR <br /> Commissary Name L & 4w�� FA# <br /> Address t.00M E �A yr N Bus. Phone 01A(A• X10 6 0 . 415 �0 <br /> City 0C_ �al� Zip ��,y�i Owner/Operator C-\ <br /> n: n Y1 C�tF.�k <br /> Check all appropriate services provided:: <br /> Wastewater disposal 3-comparbnent sink cal hook-ups <br /> olid waste disposal EZ Food preparation :/To'let and handwashing <br /> lot&Cold water for cleaning M Store refrigerated food P ble water <br /> 0 " dry food/s lies _9 Ovemight parking Vehicle wash <br /> I, (o AlAfIX 1//}/u , hereby state that the information I have provided is current,true and <br /> correct to the b of my knowledge,an eets the Califomia Health&Safety Code requirements. If the food facility <br /> operator f ' tomply with the co Ens of this agreement, or if this agreement is modified or cancelled, the <br /> commiss ry own shall notify <br /> Signature Date <br /> 3. To be coEn leted b the ENV HEALTH 'urisdiction 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 952051 T 209 468-34201 F 209 4640138 1 www.sjgov.org/ehd <br />