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SAN JOAQUIN Environmental Health Department <br /> COUNTY— <br /> tae ss grows here. <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 170Ug k\' i r1 L264 e r Lic. Plate# IiF ?3-* I <br /> Owner/Operator Name ri4 , n LJk" <br /> Business Mailing Address t$j A rp— Dr- <br /> City T StateL.LZipG53 G Bus. Ph.(Slal83� r1o41 Alt. Ph.(5i o) SSa -997-7A' <br /> I, k.MAQM &nEhereby state that the above information is current,true and correct to <br /> the bestmy 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 h/UIIP, DateglZ3 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name La In"',5ar ioi Mook4o FA# <br /> Address 1211 S• 4" 54rez- Bus. Phone (a 04) F5 -3661 <br /> City AoiO e5.V Zip 85351 Owner/Operator (10/d 5"go 60mm%3542rg1 /nc <br /> Check all appropriate services provided: <br /> Gp Wastewater disposal P 3-compartment sink Q Electrical hook-ups <br /> k3 Solid waste disposal JR Food preparation Q4 Toilet and handwashing <br /> 0 Hot & Cold water for cleaning P2 Store refrigerated food 13 Potable water <br /> 10 Store dry food/supplies IM Overnight parking 11101 Vehicle wash <br /> I, Mory ui5 C rVZ , 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 dd _� Date0111g /25 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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.sigov.org/ehd <br />