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SANJOAQU{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 completed by APPLICANT <br /> Business Name S t II ( N l &Cr Lic. Plate# J Lk25-7-7 7 <br /> Owner/Operator Name C 11_ BEv' 56ka mD <br /> Business Mailing Address 75( R.&7u- P_C- 4 Uc- <br /> City ATARDP State�Zip 330 Bus. Ph. &S 21414_32 Alt. Ph. <br /> 1,S2 I.BERT SER/ f l 6 , 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 and pen ties. <br /> Sign dturt Date 712,5-12—6 2.7i <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> a <br /> Commissary Name (LN JDA) C_X-ralMG � FA# <br /> Address 17(7- 6 1.IAL663 ST', Bus. Phone b�0 zQ,q Sy(� <br /> City, aCdcTO 4, M Zip?6-2-c'/. Owner/Operator &9 T_ t eAld <br /> Check all appropriate services provided: J <br /> o Wastewater disposal 03"3-compartment sink r Electrical hook-ups <br /> g$' solid waste disposal [[f�ood preparation L`�Toilet and handwashing <br /> L�Hot&Cold water for cleaning tl2'Store refrigerated food LA�otable water <br /> q Store dry food/supplies vemight parking G Vehicle wash <br /> I, fiRT Ti R 110 6 , 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 owneysl;all n ti E?p immediately. /J <br /> Signature (/�!d/ ( Date 7 �L 62—,1— <br /> Signature <br /> 2 <br /> 3. To be corn leted by the ENV HEALTH jurisdiction outside 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.sigov.org/ehd <br />