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SANolOAQUIN Department <br /> Environmental Health De <br /> COUNTY— <br /> Greatness grows here. <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 b APPLICANT <br /> Business Name ,—T—D U 4 Lic. Plate# 'A M S S <br /> Owner/Operator Name <br /> ndAe �o2v�A •�'2.7 <br /> Business Mailing Address <br /> City fid+ 1 o c K StateCVtZip__1S 3S o Bus. Ph. Alt. Ph. <br /> ue' hereby state that the above information is current,true and correct to <br /> the best o my knowle a 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 o�� R ewelS 2 Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name La ( .orniSorla /gc2jeS4p FA# <br /> Address lo?l (. a -;'9` L51rwe4 Bus. Phone 901)3353 3(163 <br /> City 1g6b&56 Zip 45'351 Owner/Operator �Lw Aeve the <br /> d � <br /> Check all appropriate services provided: <br /> ga Wastewater disposal M 3-compartment sink A Electrical hook-ups <br /> M Solid waste disposal IM Food preparation M Toilet and handwashing <br /> JO Hot& Cold water for cleaning ® Store refrigerated food ® Potable water <br /> jja Store ry food/supplies ® Overnight parking ® Vehicle wash <br /> I, Y-k Lv is-t"ruz , 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 /> Signature%AA'iG�i/_�J Date_;Ag/22 <br /> 3. To cam leted 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 nue I Stockton, Califomia m I T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />