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SAN�JOAQUIN a <br /> ( J Environmental Health Department <br /> Lam'>>?t: —COUNTY-- <br /> Greatness grows (sere. <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 L clY � A S I C e GlCbl Yn Lic. Plate# <br /> Owner/Operator Name Dian a Jcivre9Ui LU,)gY10 <br /> Business Mailing Address 2.0552 N Vq YI 1 R_V. IC AVC <br /> City StC bbl state 6A zip '152D5 Bus. Ph. 409-8S' -q'532 Alt. Ph. 'hi)5-854 -'1 <br /> I, Di 011 a 1Ta U reg U) LUjaND 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 enaities. <br /> Signature Date 05 202-7_ <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name ' 1 C_K N G O e ' C-P,E A M FA# <br /> Address 3 � I Z. E M jrAl F-R. Lf E Bus. Phone 'D-q- <br /> City STo CC"Ta/V Zip �1 2Sa,SOw er1'r/Operator o w-ne�y q w n <br /> Check all appropriate services provided: O <br /> (7 N Z <br /> ❑ Wastewater disposal ❑ 3-compartment sink 1{�lectrical hook-ups m O <br /> ❑ Solid waste disposal ❑ Food preparation M-T�oilet and handwashing Z g O <br /> Hot&Cold water for cleaning E]'Store refrigerated food ❑ Potable water Z <br /> [3nmm <br /> ❑ Store dry food/supplies 13-Civernight parking ❑ Vehicle wash D ;0 n <br /> (D > � <br /> I, hereby state that the information I have provided is current,true and N < M <br /> correct to the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility O M D <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the (A 3 <br /> commissary owner shall notify the EHD immediately. <br /> Signature _C7�� " -0-tea.. Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin 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 4640138 1 www.sigov.org/ehd <br />