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SAN JOAQUIN Environmental Health Department <br />COUNTY- <br />Grco(, nss 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 by APPLICANT <br />Business Name �]- IQ�'J n Oe S Ly,,Pcti A � C ic. Plate # 23aax t1 I <br />Owner/Operator Name LY«M k - k E° r Xe rYkA <br />Business Mailing Address llk� a:k.j S k . 1 • o• %O,�. r)1 <br />Cityfy'N(t'T`Phcx) State-(TiZip 904 Bus. Ph.,�;Ipq- Alt. Ph. -0� <br />I, ICtC ' R; xe;-07.4 , hereby state that the above information is current, true and correct to <br />the est 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 disco intTe�, t}�e pe it holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and pe (ties. `� � � <br />2. To be completed b� t/COMMISSARY OWNER/OPERATOR <br />` "' �l <br />Commissary Name �- & i i��:-- (_0 •-4U 4 �FA# / / <br />Address � �n1 S:7 Bus. Phone '209 oa3� 'g 79-// <br />Check all appropriate services provided: <br />Wastewater disposal l;43 -compartment sink �te€lectrical hook-ups <br />,J!f::�tolid waste disposal Food preparation q Toilet and handwashing <br />0�'ktot & Cold water for cleaning `Store refrigerated food Potable water <br />Store dry food/supplies Overnight parking Vehicle wash <br />I, �rt r� ✓1 >� -�� 31�">>^ , 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 ow s I notj�t the EHD immediately. <br />�� < . <br />13. To be completed by the ENV HEALTH iurisdiction outside of San Joaquin Co. I <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 Signatu <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 />0V1 <br />f��...- <br />