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Environmental Health Department <br />COUNTY <br />Greatness 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 />t To be completed by APPLICANT <br />Business Name laCO S 4 <br />Owner/Operator Name etaby-N eA -Lay r rc( <br />Business Mailing Address kI\S jud--YrN. <br />City Q\ eca stateCi- zip qB5. pif2o cai-s -u(4 f1-Alt. 1410003 -z_ct <br />1, )qC.I1r1 a Sala-Lake- , 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 />SignatureH3Y\ 0.1,.C\Y CiQ'ic\Qitattai-GY Date \ lig I-2:2_ <br />2. TobAk cornpleteaby_ :0 L. <br />Commissary Name La Coeviisar /I( 0 OtP-S-1-0 F A# <br />Address V1,..\\ S. -4-#1' <br />City <br />- <br />City MtickSVk? Zip q57,5i <br />Check all appropriate services provided: <br />ErWastewater disposal 123-compartment sink <br />[2( Solid waste disposal fE "Food preparation <br />13/Hot & Cold water for cleaning E"Store refrigerated food <br />EiStore dry food/supplies "Overnight parking <br />Rack Lui‘; Cxu , 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 y. <br />Signature <br /> <br /> Date tlf/q(21, <br /> <br />3.1o be cortifilifeW Vrigatibli FOt "OA an; o <br />The commissary is located in 5-C1A Tr-31S L4 LA e•:7 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 />FENS Signature --\:\ <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />Lic. Plate #27"-L-N t40(!) <br />Bus. Phone <br />Owner/Operator rn 54nrcje cyhym;c5av, /tic. <br />Er Electrical hook-ups <br />l "Toilet and handwashing <br />Eat Potable water <br />liVehicle wash <br />Date 2-7--