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S AN--�JOAOUINEnvironmental Health Department <br /> —COUNTY— <br /> COMMISSARY <br /> OUNTYCOMMISSARY 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.corn l by APPUCANT . <br /> Business Name Lic.Plate <br /> Owner/Operator Name pG.ZCtA'LzC — ; <br /> Busin Mailing Address <br /> City ' '�+ �� State 54 Zip S, 3� Bus. Ph. ��'–��3 7'�67 Aft. Ph. <br /> I,A`jdi 1Ci'Q U k Ci ,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 Califomia 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 ofEce may-result in permit <br /> revocation and genalties. (� <br /> Signature C Irl(' \' (tel - Date <br /> 2:To be cam feted b COMMISSARY-OWNEFUCIPERATOR <br /> Commissary Name--LA Caonef-C-. FA# <br /> Address aOltc E rnl'A�7 Bus. Phone 01 }A • Lj ��� • Ll5 7C <br /> City 0�0 4� Zip &I S 2,,D6A <-n e, <br /> Check all appropriate services provided: <br /> Wastewater disposal 9"3 ompartrnent sink El 'cal hook-ups <br /> Solid waste disposal 0 Food preparation C'Iatable <br /> "let and handwashing <br /> lJ P <br /> i Hot&Cold water for cleaning ®��O�vemight <br /> refrigerated food itis water <br /> _ti <br /> ;el <br /> ore dry food/supplies parking vehicle wash <br /> ,hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,and the California Health&Safety Code requirements. If the food fatality - <br /> operator fail mply with the con ' ns of this agreement, or if this agreement is modified or cancelled, the <br /> commis own�r shall notify the D imme�'iately,_ <br /> �- � '���•— �� Date ��- / - �L ,� � <br /> Signatu <br /> 3. Tobe completed b the ENV HEALTH 'urisdicti011outside.o€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 notify EHD if the status of their operating permit changes. <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton,California 952051 T 209 468-34201 F 209 464-0138 1 www_sjgov.orglehd <br />