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SAN JOAQUIN Environmental Health Department <br /> .......-CC)U NTY--- <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 /> NT ; <br /> Business NameUic. Plate# <br /> OwnerlOperator Name AwLee- D4_4tL� � ke�A <br /> Business Mailing Address lo6q Klr�wavc 'Dr, <br /> City LOCQ I State QA Zip 95ZLI 2- Bus. Ph.(U%_-T9-13Lf 0 Alt. Ph. LZog)601-q'11 e <br /> 1, May-,Iv5 DeA-,c& . 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 9 Date <br /> 12. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name iZj'A7A0 L'(_C• FA# W- <br /> Address 54-pek6i, S-1, :V Bus. Phone f() 62S 1103 <br /> City-1�-O_( Zip R S2`fi0 Owner/operator <br /> Check all appropriate services provided: <br /> E3 Wastewater disposal E3 3-compartment sink C3 Electrical hook-ups <br /> 13 Solid waste disposal 13 Food preparation 13 Toilet and handwashing <br /> E3 Hot&Cold water for cleaning 13 Store refrigerated food 13 Potable water <br /> C3 Store dry food/supplies W Overnight parking U Vehicle wash <br /> 1, (CY- —, 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 QwnaLs_ka"o' e EHD immediately. <br /> Signature Datelvlz/� <br /> I�3 TU be compfet6d ti thd ENV HEALTH jurisdiction outside of San Joaguin 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 952051 T 209 468-3420 1 IF 209 464-0138 1 www.sigov.org/ehd <br />