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S A N J OA Q U I N Environmental Health Department <br />COUNTY <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 />Business Name (✓ L C_karrtLic. Plate# 7A 2/ 5r%d <br />Owner/Operator Name lawtt ra dcLo4 -ZAL'Z- <br />Business Mailing Address 514 Mxkt cwbi rc( <br />City. L0CG 't Statd° W Zip 95 2Bus. Ph.�7/9-So67 7 Alt. Ph. <br />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 and penalties. <br />Signature9w44,oro (Ifel. Date <br />Commissary Name_ l6knmj AareyAzgenk, FA# <br />Address_ 62/) _S Sa&gP`1rtr Bus. Phone 62-01) .2.2y - R$_3v <br />City' L619t Zip 95ayv Owner/Operator �ilCdareiYU GLhoQ <br />Check all appropriate services provided: <br />awater disposal <br />waste disposal <br />& Cold water for cleaning <br />Store dry food/supplies <br />W_3 -compartment sink <br />ood preparation <br />/store refrigerated food <br />®' Overnight parking <br />'lectrical hook-ups <br />m Toilet and handwashing <br />01Potable water <br />®-vehicle wash <br />I, Kdhl; "55-ttry %e 1 , 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 owner shall notify the EHD immediately. <br />Signaturei/i Date <br />3f , <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 />RENS <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 />