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SA KJ OA Q U I N Environmental Health Department <br /> COUNTY <br /> Greatness grc <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 Moo L'\l.Lh M C,S t-,-�jj LL L Lic. Plate# `j 0 .6- -LW <br /> Owner/Operator Name M A '_ )'-) A uu;-I j Pel C\7 IV i L <br /> Business Mailing Address Z1-11 k (- � 11t S I <br /> City 31�)ZA-TUPJ State_aaZip C45205 Bus. Ph(20910 3533 Alt. Ph.(20L)) IcyG, 14�(u� <br /> I, M ACC6 A LtC-1 j MC O,4 ui t;L , 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 /> Signature �/'�i*_. 1 �/) Dated 5 / D 1 11023 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName 1,uCK CL k/1,;IEA# <br /> Address 1111 . �j fJ w o tJ Y 1 Bus. Phone LZ0tt) 2h - I <br /> City J 1 u)�r-1 u&) , [ A Zip Owner/Operator flAC7 -Theda <br /> Check all appropriate services provided: WA-5If O Iv LU <br /> pq Wastewater disposal ❑ 3-compartment sink ❑ Electrical hook-ups <br /> ❑ Solid waste disposal ❑ Food preparation ❑ Toilet and handwashing <br /> ❑ Hot & Cold water for cleaning El Store refrigerated food 13 Potable water <br /> ❑ Store dry food/supplies ❑ Overnight parking ❑ Vehicle wash <br /> I, A K 1, 111�A� , 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 comp! wit4 the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner sh II fy the EHD immediately. <br /> Signature Date 0 /0) /2(?? -3 <br /> [3. To be completed by the ENV 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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />