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OWN <br /> ° SANJOAQUIN Environmental Health Department <br /> —COUNTY---- <br /> F Greorness grows h rr. <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 UINTA&Yr- I�E<�y Am FnnjZT Lic.Plate# <br /> Owner/Operator NameV7k-;aNOA (fAsi t LAS <br /> Business Mailing Address Z?iZy- Long lslcwA Dr_ <br /> IJ <br /> Citye,- A(Y I<4m /StatefA,Zip067OGBus. Ph. Alt. Ph. <br /> I �re ,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 agcLpenaltiesJ <br /> // nn / 7 <br /> Signature Date�(n Il J 1 262.7 <br /> 2. To be completed by COMMISSARY OWNEWOPERATOR <br /> Commissary Name 4-11*/C z !J/ FA# <br /> Address /� r S4U f24- Bus. Phone / - 9-f <br /> city, Load Zip_!?I Owner/Operator /.moi l=flil <br /> Check all appropriate services provided: <br /> Wastewater disposal 0 3-compartment sink KElectrical hook-ups <br /> Solid waste disposal O Food preparation 0 Toilet and handwashing <br /> Hot & Cold water for cleaning 0 Store refrigerated food WPotable water <br /> 0 Store dry food/su//ppplies 1K Overnight parking F Vehicle wash <br /> I, mc._ n/ , 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 ' e <br /> Signature Date <br /> 3. To be com feted 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 />