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SAN J o A Q U ( N Environmental Health Department <br /> --COUNTY--- <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 com letedd by <br /> 0.cGAPPLIICANTI �--&1 v - <br /> BusinessName .La r\ `S \\p0.S1Tl __Cov- � Lic.Plate# LLL- I1 <br /> 3C& <br /> Owner/Operator Name R C1YCAU[� <br /> Business Mailing Address ��f e tf vl M 2-(Jo <br /> City VI &VA Sta\te b Zip Bus. Ph.X0914(—2,I KS Alt. Ph. <br /> I, �U eA R' `�TfCk&k • 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 andel penalties. <br /> Signature v���1�/X� 9 �rl� V Date—413 '--Z <br /> 2. To be Completed by COMMISSARY OWNER/Op <br /> Commissary NameENa <�_, �' S l��s�wyrl19l FA## <br /> Address R L s" _� Bus. Phone SS ey-3 <br /> City c N Zip %S 1--Cr S owner/Operator P .a e <br /> Check all appropriate services provided: <br /> [?/Wastewater disposal W3-cc rnpartment sink 13 Electrical hook-ups <br /> ® Solid waste disposal rood preparation 04oilet and handwashing <br /> EY'Hot & Cold water for cleaning fore refrigerated food ❑ Potable water <br /> Store dry food/supplies E3 Overnight parking p Vehicle wash <br /> Q4= 5 u 5 4 o ;P e ;E!r— ' 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 c hcalled, the <br /> commissary owner shall notify the EH immediately. <br /> ignature J (�,�/'Q �— Date (J l ' <br /> 3,,To be cot ;leted by the ENV HEALTH:•ur�sdicfion� fou srde of San Joa uin 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 />