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SAN �JOAQUIN Environmental Health Department <br /> --COUNTY— <br /> r r'O tnr55 grow, horB. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 4 Caterer <br /> Complete sections 1 and'2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> ir <br /> Business Name LolvA '/& L ////PJ(/ 4A) -FJ6P Lic. Plate# <br /> Owner/Operator Name hFzu S F P'0V'fAA- <br /> Business Mailing Address 1127 4Al2/4jr Zw <br /> City Slzq�7 X) State_eZkZip )/D Bus. Ph.ZCF,- S97-94I`(Alt. Ph. <br /> 1, , fn1 Qi USA 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 rmit # must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. - / <br /> Signature / Date G) 03/�i1 i <br /> 2. aTo be com_leted b COMMISSARY-6W_N_ER%OPERATOR <br /> Commissary Name W ) t`:X `CCX FA# <br /> Address( P20 �,��(`A('_�()l`(�Q1� (J Bus. PhoneL1061) Z ZLA-9333C4 <br /> CityZip 2L4 0 Owner/Operator �W � t CC <br /> Check all appropriate services provided: <br /> j Wastewater disposal 3-compartment sink A Electrical hook-ups <br /> 'A Solid waste disposal -Er Food preparation ,!,Toilet and handwashing <br /> _" Hot& Cold water for cleaning 't Store refrigerated food X,Potable water <br /> /Store dry food/supplies Overnight parking `.Vehicle wash <br /> I, l DMrn1�--fXU L�LZ`te ffl , hereby state that the information I have provided is current, true and <br /> correct to the best of my4nowledge, 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 spall notify the EHD immediately. <br /> SignatureDate ® ZZ <br /> °3. T0';i 60ni01ete J the ENV HEALTH 'urisdfction outsid', _ San Joa u.in,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 /> I <br /> 1868 E. Hazelton Avenue i Stockton, California 952051 T 209 468-3420 1 F 209 464-0136 1 www.sjgov.org/ehd <br />