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;i'°4"°° SAKJOAHIN Environmental Health Department <br />T <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 />Business Name \! I \ L :7 \ Y12 Lic. Plate # <br />Owner/Operator <br />Business Mailing Address 1 � �?- N. Wu n �& � - :b? -7 / <br />Cit yMhnc - 1�- State l i-1Zi�'G�?) Bus. Ph./ls'1.(0(r / <br />UjUjO1 Alt. Ph. <br />" <br />I, J� vo Z 111 l (u , 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 />commisry7 disconE;;7 <br />rmit holder must notify the EHD. Failure to notify this office may result in permit <br />revoca ion and enal(� jCSignature - Date vl 2J'Z 2— <br />Commissary <br />Commissary Name La Cnm�`sc�1a lLfmalesJv FA#. <br />Address 1.211 4, J�J- Bus. Phone C2000 338 366 <br />City A'QddfikQ Zip 95351 Owner/Operator <br />Check all appropriate services provided: <br />Q Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br />1p Store dry food/supplies <br />0 3 -compartment sink <br />13 Food preparation <br />01 Store refrigerated food <br />R Overnight parking <br />13 Electrical hook-ups <br />1A Toilet and handwashing <br />Potable water <br />Vehicle wash <br />1, Aa'h /_urs--Crld? , 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 />Signatures „ �/�� _Date ,3/ill t <br />be d; - V SII i s is t6 ide of Jn ut'n d <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 r Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www,sjgov.org/ehd <br />