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Environmental Health Department <br /> SAN J 0 A Q U I N <br /> COU NTY-- <br /> Gr�atness grows herr. C_ 1''e& <br /> and <br /> COMMISSARY AGREEMENT sev1'Ct .19 <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 b APPLICANT <br /> Business Name Ll LI a,y(-- Lic. Plate <br /> Owner/Operator Name n L I L A k <br /> Business Mailing Address ►4 Pf k e IS <br /> City Sip(1 j t) ) State_�&Zipql�QCBus. Ph. S 10 SSa-I (of.(3 Alt. Ph. <br /> I, `'1 0 L-' L 1 3 fu(_ , 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 pen ies. i I <br /> Signature Date ('a3 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 1)A) �A) CA-T Y 1L6 -T ZUCIC C1L"dFA# <br /> Address n CZ S-V Bus. Phone(a0C1) 2q �S"rJ�� l W <br /> City�jj 0CK-J&j Zip_ Owner/Operator <br /> Check all appropriate services provided: LU ()544 CN LY _QA, <br /> Wastewater disposal E3 3-compartment sink 0 Electrical hook-ups <br /> Solid waste disposal 0 Food preparation Toilet and handwashing <br /> *Hot & Cold water for cleaning [3 Store refrigerated food Potable water <br /> 0 Store dry food/supplies O Overnight parking (\ o Vehicle wash <br /> I, Akk _FI CA QD , 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 ith the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner notify the EHD immediately. 2 <br /> Signature Date 5 )T/a <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 />