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Date <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />--COUNTY — <br />Greotness grow ,. here, <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 A- y-) A-6 j .A--0<, r\a ritC{ v- a Lic. Plate # V 2 s-23 <br />Owner/Operator Name PA tA \9 <br />Business Mailing Address 11420 C. 1,341 h o -f- St <br />City c5("b ecfr‘ State 04 Zip 9 570S Bus. Ph. ( 2_ 0 c() 6 0 7 33251t. Ph. <br />I, rIA-Gori 9 1 P1a4ine -Z , 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 Date )2_-1q - :2-0 23 <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name L.A Co Yr 'et- ci CA:1 Co c p FA# <br />Address 2-9 0 0 6 , 1-1-6A ,, d nCi WC(-1 Bus. Phone 2- 6 ci - 1-1 VI - <br />City cbtOck.i-un Zip qs 2_0s Owner/Operator 61,1Z--. lt eVtipti A- )- ne+-1- <br />Check all appropriate services provided: <br />rf Wastewater disposal RI 3-compartment sink li Electrical hook-ups, <br />Ai- Solid waste disposal cia Food preparation ErToilet and handwashing <br />gkHot & Cold water for cleaning 0 Store refrigerated food 0 Potable water <br />0 Store dry food/supplies 944 Overnight parking 0 Vehicle wash <br />I, ft,r\ LA lb c, .{. cey-Nu. s , 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 s all notify the EHD immediately. <br />Z Signature <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 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd