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SAN %) A Q U I N Environmental Health Department <br /> —COUNTY-- <br /> : Greotness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility t Caterer <br /> Complete sections f 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 /"l/1c4o Aquas Frescos Lic.Plate# yVl3g5/g <br /> Owner/Operator Name L, x, -Verja 90ry 5 <br /> Business Mailing Address 16160 Crane Awd <br /> City,�-Qo k cla� State CA zipg5361 Bus. Ph. (acq)8oq-(CDR Alt. Ph. <br /> I, 6X 119l1Pn1;1' 17on"PS ,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 penalties. <br /> Signature ACX 10 UC h;a Date <br /> 2. To be corripletedby COMMISSARY OWNER/OPERATOR <br /> CommissaryName /_a (oyn i sar i s /�ade.5 Ftp FA# <br /> Address 1�2I1 .'j 54reeJ- Bus. Phone 69017)33'$-3663 <br /> City.14oa(es-Fn Zip 9535/ Owner/Operator (-o(c( S-J-oroae �nmm S r�.� lnc• <br /> Check all appropriate services provided: <br /> (a Wastewater disposal ® 3-compartment sink 12 Electrical hook-ups <br /> ® Solid waste disposal 13 Food preparation 12 Toilet and handwashing <br /> ® Hot& Cold water for cleaning ® Store refrigerated food 13 Potable water <br /> TI Store dry food/supplies 0 Overnight parking 10 Vehicle wash <br /> 1, Mark Lv is rru;L , 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 /> Signaturet (arr a Date /0 2o/;7a <br /> 3. To be completed by the ENV HEALTH 'urisd&ction outside of.San JQg uin Co. <br /> The commissary is located in 4bA4fi ,14 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_,Z/_a Date lo���say2� <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.slgov.org/ehd <br />