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9-- SAN JOAQUIN <br />COUNTY <br />Greatness grows here. <br />QSItSt23 Signature Date <br />Signature <br />3. To be comp e e <br />Environmental Health Department <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 />1. To be completed by APPLICANT <br />Business Name ALEX bi3Q LA._ c . <br />Owner/Operator Name AsujoLnart) R 0 oia-ro <br />Business Mailing Address 223 • V\taelna-r Ave_ <br />City ST-0CAc-TO State CA Zip ci52.16 Bus. Ph. (20`t)008:S2-6,0 Alt. Ph. <br />I, Al a-AC Oa ft, -RD ‘CrICLCID , hereby state that the above information is current, true and correct to <br />the besi of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br />Safety Code, and an oaquin County Environmental Health Department (EHD) requirements. If the use of the <br />commissary i • i-conti ed, the ermit older must notify the EHD. Failure to notify this office may result in permit <br />revocation a r. • - nalti s. <br />Lic. Plate # JFL3t <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name ST, °GK.-COI-I 6-0k-L1-101..1.T1 Cre.- •kE.t•3 FA# <br />Bus. Phone (2/3) 60E3 -54-456- <br />City s-roc.K..-c-DN-k Zip qS 2 o z Owner/Operator LE.,-C3N.EL ACJiu—o 60- Foov.36Elk <br />Check all appropriate services provided: <br />Er Wastewater disposal <br /> 3-compartment sink <br /> IZI Electrical hook-ups <br />a Solid waste disposal <br /> <br />fa Food preparation fa Toilet and handwashing <br />Hot & Cold water for cleaning El Store refrigerated food <br /> rif Potable water <br />'in Store dry food/supplies CI Overnight parking 0 Vehicle wash <br />Lcow,e-L c_AsTILLO , 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 p y with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary o er s II notify_the e mediately. <br />Address EL 0 A,D.0 <br />Date if),./ke /23 <br />NV HEALTH jurisdiction outside of 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 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd