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SAN .JOAQUINc <br /> [�I�v6rrol�lrneaFa��,l� ��eaiii�u Da�lolrtlrnenu <br /> —COUNTY-- <br /> Graetnc •; „rr. vs her_=. <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_LA VioTAcir- s�N l fknji:) Lie. Plate# <br /> Owner/Operator Name___�7tz-Et,39/-\ I (frksiAS <br /> lL <br /> Business Mailing Address Z�Z/� Lona V Slrt Dr. <br /> city,f,- Act K-t na StateLZip 0620 G Bus. Ph. Alt. Ph. <br /> I,:� / <br /> tr��c C s, iLs, 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 an enalties n / <br /> Signature Date /l 1 3 1 2UZ <br /> 2. To be completed by COMMISSARY O <br /> WN <br /> ER/OPERATOR <br /> Commissary Name /�riX/Xie'("fes Y (J U"GyI FA# <br /> Address U?% �r - ✓CiYii�t� , i .S Bus. Phone <br /> City =Q' Zip ! ji Owner/Operator vJ'Z12_ <br /> Check all appropriate services provided: <br /> q Wastewater disposal 13 3-compartment sink ffi Electrical hook-ups <br /> Iii'Solid waste disposal E3 Food preparation Toilet and handwashing <br /> i <br /> Hot & Cold water for cleaning Q Store refrigerated food WPotable water <br /> 0 Store dry <br /> yfffood/suJpplies { Overnight parking FVehicle wash <br /> I, 2Y=c;lti/ , 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 th HD ie 'ately. <br /> Signature l! Date h '� <br /> 3. To be completed by the 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 />