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(�e,j- <br /> ,ve e d2 P12 <br /> SAN !OAQUIN Environmental Health Department <br /> LouwTY <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 Y36tftS CkQVAT10t.1S LLC Lic. Plate# <br /> Owner/Operator Name 1-A-R-Et4 -V;A /AY2- <br /> BusinessMailing Address Sas W. CAi,lCA00 cT- <br /> CityMM! �vJ VtQWState(nA Zip FIs I Bis. Ph. (st^^) aov-t2H-DAlt. Ph. <br /> I, ISN I-Ps,bA44— ,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 Joaqui County vironmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, per ' older must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalb s. <br /> Signature Date <br /> 2. To be conipleted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name La at"isori4 /MDo(e5{-0 FA# <br /> Address /R!/ S. 7"' 54-CeCi Bus. Phone 0404) 33$-3663 <br /> City /4vdeM• o Zip 4535 t owner/operator Col !off <br /> Check all appropriate services provided: <br /> 12 Wastewater disposal ® 3-compartment sink M Electrical hook-ups <br /> M Solid waste disposal M Food preparation 0 Toilet and handwashing <br /> N Hot&Cold water for cleaning III Store refrigerated food 13 Potable water <br /> ® Store dry food/supplies 18 Overnight parking ® Vehicle wash <br /> I, /4*4-k Loi 5- Gr'u 2 , 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 /a6,o9a <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 209468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />