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SAN 10AQUIN Environmental Health Department <br /> .--.—COUNTY- -- <br /> COMMISSARY <br /> ---COUNTY- -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 50bor Lc�r, n Lic. Plate# q(JA 4383 <br /> Owner/Operator Name Eirv,er ma-lia L)e55iCC. M04enro5o <br /> Business Mailing Address E. mornpasc+ gr( <br /> City Steck k� State_/ Zip q5a )5 Bus. Ph. 5-10 951 23/9 Alt. Ph. <br /> I, L 1 veer A-4-4�q , 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 penalties <br /> � Date Z-Z Z- <br /> 2. To be completed by COMMISSARY OWNEMPERATOR <br /> CommissaryName La ��m;Sor;p ^/(hr1¢s10 FA# <br /> Address 1211 S- *" S} Bus. Phone Caog133�-3��3 <br /> City modbslo Zip g5351 Owner/Operator (old Shorage Cowmissc.u, Inc.. <br /> Check all appropriate services provided: <br /> 13 Wastewater disposal 0 3-compartment sink R Electrical hook-ups <br /> ® Solid waste disposal 13 Food preparation (3 Toilet and handwashing <br /> ® Hot & Cold water for cleaning [3 Store refrigerated food ® Potable water <br /> 13 Store dry food/supplies 13 Overnight parking C3 Vehicle wash <br /> I, M a,r L Lo;5 CwN : , 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 An _ _Date IZtLZ11-2 <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 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />