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SAN JOAQUIN 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 be completed by APPLICANT ^ 1 <br /> Business Name E L -TLCo spm- Lic. Plate#Li-FI v 'Scl Q1 <br /> Owner/Operator Name A 01)9;ES �`tt�C Q 0 <br /> Business Mailing Address 173-9 q WPL-P(nL'e7 vg' <br /> CityM4DES'i715 —State CPr Zip92, LSS Bus. Ph.�QD9• (o 18' 3383 Alt. Ph.6SDa t% 1--)-8S7 <br /> I, A FaDe-G,S SALcmoer) , 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. + cC 'I <br /> Signature��� SIA- ( �i (� U6 . Date 0 '2 �Zt <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Ze 4i2,wiSarld &aid 40 FA# <br /> Address lA I t S. � acm4 Bus. Phone (A61) 33$-364 3 <br /> City 44eAes+o Zip ?5361 Owner/Operatorlo/e( S�arout Cd«..,issa.a <br /> Check all appropriate services provided: <br /> ® Wastewater disposal 13 3-compartment sink ® Electrical hook-ups <br /> IN Solid waste disposal M Food preparation M Toilet and handwashing <br /> m Hot & Coldwater for cleaning 13 Store refrigerated food 0 Potable water <br /> M Store dry food/supplies 13 Overnight parking 0 Vehicle wash <br /> I, )stack Lw5-Gry a , 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 own�sh/alI tify the EHD immediately. <br /> Signature % ( � Datea3/a/ <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 952051 T 209 468-3420 I F 209 464-0138 1 www.sjgov.org/ehd <br />