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SAN JOAQUIN 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�� ii.(,-7,r. M 4 /G` )g.L Lic. Plate# <br /> Owner/Operator Name ka Lei- Zrl� <br /> Business Mailing Address �c/ � 4r, 4a <br /> CitY56246� -StateG Zip q Bus. Ph.�A q36 ('�- Alt. Ph. <br /> I, 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 /> � //�� <br /> SignatureAl l GeALL Date 1/ 0 � <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName L 9 Cstn iQ0 <br /> 1661 IUOkS� FA# <br /> Address <br /> I,I 1,11 S. �'' !�� ree,1 Bus. Phone 8 339 36(03 <br /> City Aokslo Zip 45351 Owner/Operator Cold, 54=5e Co�+�, Iv c. <br /> Check all appropriate services provided: <br /> Wastewater disposal IN 3-compartment sink Electrical hook-ups <br /> Solid waste disposal 13 Food preparation Toilet and handwashing <br /> 49 Hot& Cold water for cleaning far? Store refrigerated food Potable water <br /> P1 Store dry food/supplies JZ Overnight parking 13 Vehicle wash <br /> I, &14-1" ts-i5 C,Art , 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 im ediately. <br /> Signature Date <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 n�oltify1 EHD if the status of their operating permit changes. <br /> REHS Signature 1JL W � Date I—G- Z3 <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />