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SPA JOAQUIN E nvlr®inmentW Heaoth Department <br /> - --COU LAITY----- <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 /> Business Name A LEX PLA/LA I E 1—r <br /> .A in S Lic. Plate#. L 5 3 D a- <br /> Owner/Operator Name A�cj': rykio C I Cn P CA CSI C i <br /> BusinessMailing Address Y 'kNje <br /> City fI�it�1keLC, State�Zip L Bus. Ph. x,09 -AA l . 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 /> Signature MUGA& C1 �t Date / -3 zZ <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> r - <br /> Commissary Name 4a <br /> �c �r rK I c- lie I YLo, t FA# <br /> Address f Bus. Phone 2 0`�- ST <br /> City S CXbL' t Zip $ Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal 2 3-compartment sink Ly'Electrical hook-ups <br /> ,Solid waste disposal Food preparation Toilet and handwashing <br /> -t <br /> Hot& Cold water for cleaning /Store refrigerated food Potable water <br /> 3, Vf Store dry food/supplies Overnight parking M'eVehicle wash <br /> 1; �2 ✓ D 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 falls 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 /> Signature = Date 2/S 2 <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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www,sjgov.org/ehd <br />