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X12 05352_ <br /> SAN 10 A Q U I N Environmental Health Department <br /> COUNTY -- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility s 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 JA6 >5 la — Pl Lic. Plate# qct.7 I �� <br /> Owner/Operator Name F 0509TC, <br /> Business Mailing Address 15,V2- '—F9-45 G 57T- <br /> City s`D'Gl`—T(�N Stated Zip q 5-7,CC.Bus. Ph. 217y4-&12-a5-&5-Alt. Ph. <br /> I, F-c,:;50k2-To , 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 /> commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation anqpet5alties. 1 <br /> Signature �`/ a r�i� Date 661,1>2 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name La AodeS�n FA# <br /> Address /,711 S fid" S,te,4 Bus. Phone C20g133T-3663 <br /> City, .Ucdosdo Zip 85561 Owner/Operator Cold $V ,-!2X <br /> Check all appropriate services provided: <br /> l!(Wastewater disposal 0'3-compartment sink 0"Electrical hook-ups <br /> JT'Solid waste disposal [Food preparation IdToilet and handwashing <br /> V�Hot& Cold water for cleaning Ef Store refrigerated food 0(Potable water <br /> LYStore dry food/supplies Ur Overnight parking dVehicle wash <br /> I, Mark Lur5--6ry , 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 L,6102/z2. <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin 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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />