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SANAMUIN Environmental Health Department <br />s :8 —COUNTY-- <br />COMMISSARY <br />COVNTY--COMMISSARY AGREEMENT <br />Mobile Food Facility * Caterer <br />Complete sections t and 2. if your commissary is located outside of San Joaquin County also complete section 3. , <br />11 11 Te be comnlated=bV APPLICANT I <br />Business <br />Owner/Operator <br />Business Mailing Address 1124? 1,e4U � YY" <br />clStat Zip ,Bus. Php1 dp — 9S/' %/fAlt Ph. <br />1 In t4l2 n; IU0l4 j0 Al 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, <br />O�� <br />CommissaryName LA CQ Q1ag[_t"'_< rA FA# <br />Address rqgbo E "rAfA.y\A aan Bus. Phone � q - <br />�� n <br />City 0 �-O r � An ZiD 6K loci Owner/Operator C \n+ t7 cr124 t <br />Check all appropriate services provided: <br />1531"Wastewater disposal <br />3-compartrnent sink <br />olid waste disposal <br />U Food preparation <br />� / Hot & Cold water for cleaning <br />®St refrigerated food <br />iK <br />1, ( 6 A1/ <br />correct to the <br />operator faily <br />vemight parking <br />i EI cal hook-ups <br />�T 'let and handwashing <br />�etabie water <br />F�/Vehicle wash <br />6—A A16AOEweby state that the information I have provided is current, true and <br />knowledge, andshe California Health & Safety Code requirements. If the food facility <br />with the of this agreement, or if this agreement is modified or cancelled, the <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. Haielton Avenue I Stockton, California 952051 T 209 468-34201 F 209 4640438 1 www_sjgov.orglehd <br />