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SAN ]OAQUIN Environmental health Department <br /> COUNTY— <br /> .._ <br /> 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 bOoDmpjeted.by APPLICANT . , <br /> Business Name Somo FJZlorl Lic. Plate# 7Rrty73 <br /> Owner/Operator Name f v <br /> Business Mailing Address o <br /> CitycS� Al StateL2�,_Zip 2DBus. Ph. Z7-(o3'�3AIt Ph. <br /> N �� hereby state that the above information is current,_true and correct to <br /> the best of my know) ge 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 isean'nued,the permit hot ust notify the EHD. Failure to notify this office may result in permit <br /> revocation an penalti <br /> 17 <br /> Signature Date `�� 3 <br /> 2.To b c;o eted_b COMMISSARYOWNERIOPERATOR -- <br /> Commissary Name L R Ccs Ac)x C% r„\ FA# <br /> Address �ArArk,,A uk Bus. Phone ` r� <br /> City U(�Kkc� Zip (1572;5 —Owner/Operator ` \r,. p ri �r l2h t <br /> Check all appropriate services provided: <br /> ,'Wastewater disposal �'3 compartment sink - EI cal hook-ups <br /> olid waste disposal E3 Food preparation �T 'let and handwashing <br /> ;�a Hot&Cold water for cleaning 00 Store refrigerated food i P'table water <br /> 3 S,t�re dry food/su plies // Ems'Ovemight parking Vehicle wash <br /> I, L ONlI//E OtZ ,hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,and the California Health&Safety Code requirements. If the food facility <br /> operator fails t omply with the co ns of this agreement, or if this agreement is modified or cancelled, the <br /> commissa r shall notify the D i mediately. <br /> Signatur Date <br /> 3. To be compietdd-by the ENV HEALTH jurisdiction outside of San Joa Win 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 209 468-3420 1 F 209 464-0138 1 wAvwsjgov.org/e1 td <br />