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SAN iJOAQU IN Environmental Health Department <br /> COUNTY--- <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 4, 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 L L u l_ 1-I E rc,Y1 L L.. Y�� ! lel U Lic. Plate# � ��5 � C1 LID <br /> Owner/Operator Name ��/�U L '( L' Z <br /> Business Mailing Address 5,-/ ` k, <br /> City 5� �'L��C U State ��Zip�� G�� Bus. Ph. Z bq - q ,,l(; 1 U S Alt. Ph. <br /> I, AVL �L-72eZ 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 /> // <br /> Signature rilrL%/ YC'1'eZ Date /J l:'2 l 1,261z 3 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name V N W 6 l k UZK L LA/'1 c;CFA# <br /> Address ' U 11l t U A) `� ( Bus. Phone —� <br /> City ��ti( i�'I L J Zip Z() ly Owner/Operator_S{�'o <br /> Check all appropriate services provided: <br /> (a Wastewater disposal ED 3-compartment sink Electrical hook-ups <br /> 1p Solid waste disposal Food preparation B Toilet and handwashing <br /> 0 Hot & Cold water for cleaning Store refrigerated food Potable water <br /> C3 Store dry food/supplies I;i Overnight parking I,Vehicle wash <br /> I, E✓�►k� . , i hereby state that the information I have provided is current,true and <br /> corr�o 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 r 1 I��11v2 L) .� <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 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />