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X20 52q +q <br /> SAN JOAQUIN Environmental Health Department <br /> --COUNTY--- <br /> Gr-eotness grows 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 ,� }�(L1LU j� �_�?�/!�C Lic. Plate# v Cl I �'I <br /> Owner/Operator Name L III ML f)L J7� <br /> Business Mailing Address I�'��I. ;! J C (.7-- ),j-i (✓r <br /> City S ,� LIC�c ti StatefZip (J 'Z c, L Bus. Ph.20`1 `55 y Alt. Ph. <br /> 1, tiL ��IfL�L= ��(_L�7/� , 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 <br /> 2. To be completed by COMMISSARY OWNEWPERATOR <br /> Commissary Name j )fl)t L` ti 7 tk- L iC L L A I A# <br /> Address ) 71 1 r7 L� f� (�� .ti; Bus. Phone 20(1- 2-Cl <br /> City ^.� L t�/C l U Zip Owner/Operator 'S i r'� t 4)c <br /> Check all appropriate services provided: <br /> C3 Wastewater disposal IO 3-compartment sink 0 Electrical hook-ups <br /> p Solid waste disposal p Food preparation V Toilet and handwashing <br /> ® Hot& Cold water for cleaning 0 Store refrigerated food Eby Potable water <br /> 0 Store dry food/sup lies 13 Overnight parking Vehicle wash <br /> I, f F--c S C; hereby state that the information I have provided is current,true and <br /> correc 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 th',.;F ID immediately. <br /> SignatureDate <br /> � 4 <br /> 3. To b&16ompleted 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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />