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SANrlOAQUIN 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 />1. To be completed by APPLICANT <br />%� <br />Business Name L 1,l /S rbi—i . - 64 / P off- Lic. Plate # / 3Q 9 9'7— r, <br />Owner/Operator <br />Business Mailing Address e7(�_ AY/.R-ddf- ARZ/O7'"' <br />city_ uState�Zip Sao Bus. Ph.od 0 i - 39S = efi%.�It Ph. 5_0 - r 9l`- Do 3 � <br />1, .4"1 /V '9 8OCl7 AI 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 Califomta Health & <br />Safety Code, and San Joaquin Cou Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinued, the it holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />Cinn�h,ro nAtA <br />12. Tobe compieWd.bv COMMISSARY OWNER/OPERATOR _ _-J <br />Commissary Name L. R (-(-) (Scm- c,% (A\ FA# <br />oaa.o« 00IIM-) {- kAr..rA _.. r.mi. Rim PhnnP 1W - L%%LI <br />City -�D�C) <br />Check all appropriate services provided: <br />ff"Wastewater disposal " 3 compartment sinkEl cal hook-ups <br />Solid waste disposal 0 Food preparation T 'let and handwashing <br />0 Hot & Cold water for cleaning 0 Store refrigerated food al le water <br />D 5 e dry food/s767!4440 <br />plies MI -Overnight parking Vehicle wash <br />I, p�^j/ � 6/Q4 4 0C ' 'z- hereby state that the information I have provided is current, true and <br />correct to the best of my knowledge, and me,5Ms the California Health & Safety Code requirements. If the food facility <br />operator fails 9> -comply with the cond' of this agreement, or if this agreement is modified or cancelled, the <br />notify <br />3. <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 <br />1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />