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P C)5 ti'-�53`i <br />A 002-4031 <br />S Q N ,M Q Q U I N Environmental Health Department <br />COUNTY <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer <br />Complete sections 1 and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br />Business Name �}� �u ( T{?)) n 1)P j Lic. Plate # <br />Owner/Operator Name LdU' G:rj�t7 4 <br />Business Mailing AddressZ2L --�; <br />City 1-01)1 �yStatejA_Zipf5Z-�0 Alt. <br />. 7jbc� 2 <br />1 <br />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 -- _ `� Date b / LL <br />4j'ZU 7.�i <br />2. To be <br />Commissary Name _LFA#002_/ 493 <br />Address ' (p 2 [9d N4n d Bus. Phone moi - 713`��P <br />CityZiP__T_J�_330 T Owner/Operator 5;k—A_ <br />Check all appropriate services provided: / <br />9 Wastewater disposal 133 -compartment sink 19 Electrical hook-ups <br />®(Solid waste disposal ❑ Food preparation Toilet and handwashing <br />❑ Hot & Cold water for cleaning ❑ Store refrigerated food 9(Potable water <br />❑ Store dry food/supplies Overnight parking ar Vehicle wash <br />►r {� _, hereby state that the information I have provided is current, true and <br />correct to the best of my knowledgeand 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 ownshall nol"e EHD immediately. <br />1 3. To bb/completed by the ENV HEALTH jurisdiction outside of San Joaquin Co <br />The commissary is located in S l ) V a aw ^ County. The above food facility meets the <br />commissary requirements in California Health & 8afety 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 Siqnature M-... <br />11868 E. Hazelton Avenue I Stockton, California 95205 1 T 2019 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />25/XAi l 1 tT -dQ/'GSS &Qd Tt'UG��On,4e ,h6toJ�Ll I—V -W-LA <br />