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SAN JOAQUIN <br />COUNTY <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Complete sections 1 and 2. If your commissaty is located outside of San Joaquin County also complete section 3. <br />To be completed by APPLICANT <br />Business Name Laht4 e€ z Pak (1/ a bc I NC Lic. Plate #4 V <br />Owner/Operator Name Pyee-t 5 .(h694%- <br />Business Mailing Address 12,0 I-ea:v-61 'Park Cry <br />City ficotteca., State CA- Zip 95337 Bus. Ph. (20q) 32-g- 313 Alt. Ph.,(200 6 12 - 3126 <br />, hereby state that the above information is current, true and correct to <br />the best of my knowl ge 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 />Date G:9 ;7z79/2 <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 1z? (20144/.50rici ,i(01e)5-4) FA# <br />Signature <br />I, i 9 ree 5r4dg il <br /> <br />Address 1211 S, +11 5+ Bus. Phone OA 5--3 -3663 <br />City Zip q535/ <br /> <br />Owner/Operator Cold 5-1---orvje <br /> <br />Check all appropriate services provided: <br />Q' Wastewater disposal <br />OrSolid waste disposal <br />El Hot & Cold water for cleaning <br />0/Store dry food/supplies <br />0-3-compartment sink <br />ErFood preparation <br />ErStore refrigerated food <br />0/Overnight parking <br />ErElectrical hook-ups <br />ErToilet and handwashing <br />ErPotable water <br />0Vehicle wash <br />Ork C.rift" , 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 EHD immediately. <br />Signature Date 05yo 1/2 3 <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co.] <br />The commissary is located in 61 `-;2> 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 gtatus 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.orgiehd <br />6123