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SAN JOAQUIN Environmental Health Department <br /> --COUNTY----- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 3 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 LA So o 6hl- Lie. Plate# 1 L <br /> Owner/Operator Name kA Al l V) IC)DQE 5 <br /> Business Mailing Address 1 2 bq R)A U QLVC AUE <br /> City` _�OCK1 b A) State CA Zip Bus. Ph.r Zt� )50`1-617312- Alt. Ph. <br /> [, 0 At21 it 7LIU Elm , 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 END. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signatur Date S12,2, /Z 62-S <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 0 U0 I`.) C Al �I k)L-1 DUCK C-Lk 1e_ FA# <br /> Address I I ) I S , L) UJ16/y ST- Bus. Phone L20� Z�I�S-5�✓ I to <br /> City S'(UC t :l6%U Zip I S Z O L Owner/Operator <br /> Check all appropriate services provided: <br /> 12 Wastewater disposal EI 3-compartment sink E3 Electrical hook-ups <br /> 42 Solid waste disposal 0 Food preparation 0 Toilet and handwashing <br /> 03 Hot & Cold water for cleaning 0 Store refrigerated food 3 Potable water <br /> E3 Store dry food/supplies EI Overnight parking 0 Vehicle wash <br /> I, AAf Z Tlel4i9n -, 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 complywith the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary ow r h no' th HD immediately. <br /> Signature Date P122-1_Z 6X23 <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 Siockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />