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SAN.%JOAQUIN Environmental Health Department <br /> —COUNTY— <br /> i;reuene>s gre,, eye. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections f 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 LpQ141,5 M4CXtcA4A Lic.Plate# �SZ.Z�3y <br /> Owner/Operator Name TLkLjp QAjSaEjJA 4. 1Sttu�eR S/1L/tzHR <br /> Business Mailing Address 904 S, LGOI.IOCxE A(/ <br /> CityS1—oc-4k State ch Zip S J Bus. PhQdj)y/y-4933 Alt. Ph. <br /> I-r �lJr i 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 aalties. <br /> Signature v .f 4'4::e�1ZLi�,EL� Date__y4 /at <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name t t t G d c_A—CRI h1 G 7 Ue,, CEAjTER FA# <br /> Address 17 / % S - U IUCD of 5T. Bus. Phone&e`t)2 <br /> City, �r>� Cif Zip ZS; 6 Owner/Operator AIM 'reiO4,0c) <br /> Check all appropriate services provided: <br /> p'VVastewater disposal fes-compartment sink Mr Electrical hook-ups <br /> olid waste disposal C!I U <br /> /Food preparation � Toilet and handwashing <br /> dHot& Cold water for cleaning L7 SSt�tgre refrigerated food IT/Potable water <br /> C Store dry food/suppliesM-lovernight parking M Vehicle wash <br /> I, /Y t<7— (/����' 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 /> commissaryown h t ?EHD immediately. <br /> Signature Date / 11F d Z l <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.orglehd <br /> �pol0A 15 <br />