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r <br /> SANRJOAQUIN Environmental Health Department <br /> —COUNTY- <br /> - <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility•Caterer _ <br /> CWPIetesectbnslandZ #yourcommtsaayis/oretedoutsideofSan Joequln County&ISe oortrpiele section 3. <br /> 1.To be,c= eted APPLICANT - _ <br /> Business Name �'f LL Lia Plate# a_�— <br /> Owner/OperatorName , <br /> Rusin Melling Addrr�s� �✓ y-F W 1� /� a66� <br /> qry State zip,_fr.? .Bus.Ph.,:2 /,P,P-SslAtt.Ph. <br /> I Z hereby state that the above informefion is onrent,_irus and corned m <br /> the bes or my om4edga and agree to ummza my approved cemmlssary in accordance wM Dailfomla Health& <br /> -. Safely Code,and Sen J - County EnNronmental Health Department(EHD)requi eWenta If the use o1 the <br /> oommiesery Is discondnu ,the pemut holder must notly the EHD. FaiWre to no*this office may resuH in permit <br /> revocation and penal <br /> Skjrkawm Data�z-6—ao�i <br /> 2 To be core eteSb .COMMISSARY OWNERIOPERATOR <br /> Commissary Name LA CnMP_K:C,r\ FA# <br /> Address, Bus.Phone DCCl- <br /> city �J�C)(:{�,{oyt Zmp diS 2v S ownerloperator C�r.;Q .Yt!n P.�-t <br /> Check all appropriate servifes provided/; .. <br /> f"Wasteweler disposal ISY3-comparbnent sink f� cal hook-ups <br /> WSolid waste disposal C Food preparation FV.h:, <br /> land handwashing <br /> * Hot&Cal)waterfor cleaning a Sto ref iwrdted food a view <br /> * SS�tore dry focdlsuLppIas Ovemight parking cle wash <br /> I,L ONN/E XZNAdFz hereby stme that the lmormallm l have provided Is cement,true and <br /> correct to the best of myknamvledge,and meals the California Health&Safety Code requirements. If the took!facility - <br /> Operator fads to comply with the condil'gri's m <br /> of this agreement,or if this agreement is modified or cancelled.the <br /> wirrim Bary shall notify the EH6lmnmed)stely- - <br /> Signatu G <br /> �NData ��g eG - off/ <br /> 3 To completed by the ENV HEAL i H'uftdiedw oulsidd Of San Joa uin Co. <br /> The corwkeary is located In County. The above food fadity,meets the <br /> cowitlawy r,WhmgM In Celfofrde Health&Safety Code. The above checked services are available at the <br /> above oornrnlssery_ Please notify EHD If the status of their operating permit changes. <br /> RENS Signs Wre Date <br /> 1868 E HaTdton Avenue I Stockton,Cardorrme 952051 T 209 468-34201 F 209 484-0138 1 fwwsglcv.agfehd - <br />