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SAN J O A Q U I N Environmental Health Department <br /> COUNTY <br /> (area`•,.: _ ,. . her.. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility * Caterer <br /> Complete sectiohs 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 /> //// G <br /> Business Name 1pr�;Uer-i a 00�a A ✓L1 Lic. Plate# �` ) f S <br /> Owner/Operator Name /�_(ar-Nbe l <br /> Business Mailing Address /`/aQ <br /> City S4-oL0--pn State C.+ ZipG/'5a0S Bus. Ph. (d0j)50 7 - 332 5 Alt. Ph. <br /> I, tlLav k bel 1•'_a v i n t z , 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 /> Signaturev"' aZ Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name (� 6om�50r/c A"/'"- D FA# <br /> Address <br /> /a// 5. {H �r Bus. Phone <br /> City Aaale 5110 Zip X5351 Owner/Operator <br /> Check all appropriate services provided: <br /> [-Wastewater disposal 03-compartment sink O-Electrical hook-ups <br /> [3--Solid waste disposal mood preparation 0-Toilet and handwashing <br /> 0"'Hot & Cold water for cleaning U-Store refrigerated food potable water <br /> [Store dry food/supplies [."Overnight parking G'Vehicle wash <br /> I, Korb LylS Cruz , 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 Date 03� <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin Co. <br /> The commissary is located in aanlslaus 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 �J� I� 2D23 <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />