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_ SAN JOAQUIN Environmental Health Department <br /> 44 <br /> —COUNTY— <br /> _._ <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 corn leted by APPLICANT <br /> BusinessName—&AGkt l0�tk- LLL LLC- Lia Plate# 1Klslco� <br /> Owner/Operator Name Me,+-aA s r-tckai tp- <br /> Business Mailing Address �U(V� C t <br /> City_S ai(A 3()Se- State_(:A ZipISIZZ Bus. Ph. 4ots '�6�-�j270 Alt Ph. <br /> I, �A-eAT-eche S N(Z,tri'uj: 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 Deparbnent (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 pen�III <br /> Signature �!/' � Date t <br /> 2 To be:completed-by COMMISSARY OWNERIOPERATOR -- <br /> Commissary Name L A C.Q FA# <br /> Address r�i OICC E rtyrAg,& Bus. Phone 0qOCt <br /> City �U t: }oy� Zip VIS Zo5 Owner/Operator <br /> Check all appropriate services provided: <br /> _/ <br /> :� Wastewater disposal S 3 compartment sink M Et cal hook-ups <br /> _ <br /> W"Solid waste disposal Food preparation T 'let and handwashing <br /> iHot&Cold water for cleaning13 St�o refrigerated food � ble water <br /> E3/$t/pre dry food! pnntir�enns �YOvern parking Vehicle wash <br /> I, PAW/4 Uvrt —_ hereby state that the information I have provided is current,we and <br /> correct to the best of my knowledge,and is the California Health&Safety Code requirements. If the food fatality <br /> operator ' ' to ml ly with the ons of this agreement, or if this agreement is modified or cancelled, the <br /> commis ry o er shall not�(y e p mately. <br /> Signatu f Date �� '-3/- �U <br /> 3. To be coin letedb .the ENV HEALTH jurisdiction outside ofSan: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 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />