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• J.clurp4 <br />SAN JOAQUIN <br /> Environmental Health Department <br />--COUNTY <br />Greatness grows here <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 <br />Owner/Operator Name LuA 3 <br />Business Mailing Address (fi D--- ilkt__,1/ <br />, %, a 0 u ai , t -)_ ,•\ 4, Qw _ <br />City 4-00,0-CY\ State Zip CL\ s. Ph. -k 0 -i- -Jot-t_i ,•D Alt. Ph. <br />I l___O\NS <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 d enalties. <br />IF 09.7:7 <br />Date <br />Signature <br />To be corn COMMISSARY OWNER/OPERATOR <br />FA# <br />Commissary Name <br />Address 99d <br />Bus. Phone <br />wner/Operator ZipC City <br />Check all appropriate services provided: <br />Wastewater disposal <br />Solid waste disposal <br />RI Hot & Cold water for cleaning <br />S r, dry too. upplies <br />I , C Ati/1// I-PV /tr , 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 cyditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary o er shall notifyet• HD immediately. <br />Signature <br />3. To be corn leted b the ENV HEALTH 'urisdiction outside of San Joa uin Co. <br />The commissary is located in <br />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 />Date <br />REHS Signature <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />Et 3-compa1tment sink <br />a Food preparation <br />a Store refrigerated food <br />Et Overnight parking <br />Electrical hook-ups <br />Toilet and handwashing <br />li Potable water <br />Vehicle wash <br />Date — ‘2:7)-