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m � U <br /> SANq:JOAQUIN Enviro <br /> ft >a <br /> COUNTY— o? W Tm� d e <br /> rya. j ¢ m 10 � nomv � <br /> O'9 <br /> mm <br /> ac, oaf Greatness grows here. a�N <br /> COMMISSARY AGREIYksy E <br /> k4l wh ze oovcwm^e <br /> �o� R. o „ � vv .. <br /> � . ama Zeo'.'a- X 'm <br /> Mobile Food Facility ♦ Ca g�� W w M 0 o 'r LL W <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3.—-- <br /> Business Name J C—) I x:)r-751 Lic. Plate# <br /> Owner/Operator Name I e/rrCA \ ���2���(a, <br /> Business Mailing Address 02. (N IM(II I� r+1` �2/� <br /> Cay State Ci-ZiFS3� Bus. Ph.)(P-(/[r'IPP)Alt. 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 /> comms saryi discontinued, the p rmit holder must notify the EHD. Failure to notify this office may result in permit <br /> revoca 'on andenalties. <br /> Signatur Date `I2S�Z2- <br /> CommissaryName La FA# <br /> Address l.?I( :j, �L4" 5&rAd- Bus. Phone (2oli) 338 366 <br /> Cit 1444LS6 Zip 9535/ Owner/Operator e!!1lel 5;1-00pe <br /> Check all appropriate services provided: <br /> [p Wastewater disposal 0 3-compartment sink IN Electrical hook-ups <br /> Pill Solid waste disposal $3 Food preparation 1p Toilet and handwashing <br /> 10 Hot & Cold water for cleaning 13 Store refrigerated food ,0 Potable water <br /> [a1 Store dry food/supplies Overnight parking ;I Vehicle wash <br /> I, Aifn,.t, L, ;s-CrL9 , 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 /// Date_,;/t/21- <br /> The commissary is located in 51 Ao-1 LA l 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 <br /> 1 EHD if the status of their operating permit changes. <br /> REHSSignature� Am. N'k 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 />