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A� JQAQQ� N Environmental Health Department <br /> --COUNTY— <br /> �: ,. Greatness grows here. <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 /> rr �z��J <br /> Business Name L U o c l4 e 62 yA C-hy'Zr� Lic. Plate# lD�i✓iJ r <br /> Owner/Operator Name Lfl-A?-va MtG 4c-L- aUeY'✓e ✓a <br /> Business Mailing Address 41 S3 'CAV4 -11E MPL e -5-1- <br /> city <br /> icity StC)CXTD'N StateCAL Zip 95P-0(6 Bus. Ph. 09 -'WL S3sq Alt. Ph. <br /> I, LAv 2✓', V-1 tct-4-E t.. 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. �q I <br /> Signature l f 02y� Uti-1 Date <br /> 2. To be completed by COMMIS ARY OWNER/OPERATOR <br /> Commissary Nam 4 <br /> Address Y YLt Gl Bus. Phone 2� 1 <br /> City Zip Owner/OperatorSa 44 ISS <br /> Check all appropriate services provided: <br /> Vastewater disposal E5�3-compartment sink electrical hook-ups <br /> olid waste disposal L't"Food preparation Toilet and handwashing <br /> i <br /> j'I"lot& Cold water for cleaning O Store refrigerated food Potable water <br /> .1a Store dry food/supplies CI Overnight parking 0 Vehicle wash <br /> I, L--' l— , 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 o ner shall otify the EHD immediately I�) <br /> Signature KA � Date <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 />