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SANAIAQUIN <br />—COUNTY <br />Greo tnc5c n <br />Environmental Health Department <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 1 <br />Business Name -rAcos st. ACOhic DIAL-CE Lic. Plate # (20 7 55 R. I <br />Owner/Operator Name .CIS.e uit,5 014.41-5(zec ex*-Tss <br />Business Mailing Address 1. tie)1 5 0-1120 A V6 <br />City 5-1-ocietv4 StatCA- Zip957-03Bus. Ph24:7rglIMAlt. Ph. <br />LA/A ti-t_ rintro. r, 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 />5 e.., L. vi• 5 pet-rem C Date °Wog/202Y revocation and penalties. <br />SignaturS, <br />[2.10 be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name LcA Co yney-c_i c.,A c...o-r- p FA# <br />Address 9-40 ip t. -\-(..r c,\.‘nci Wc,..,.1 Bus. Phone 2 0d1 _ LI G,L4 - 4S70 <br />city `>-0(.-1-k.Vc,--,--. Zip CS2_0 C Owner/Operator (.4 -Q.- ' ' (AAA <br />Check all all appropriate services provided: <br />4 Wastewater disposal 5K. 3 - c 0 m p a rt m e n t sink Or Electrical hook-ups <br />0 Solid waste disposal 0 Food preparation tj l Toilet and handwashing <br />Er Hot & Cold water for cleaning 0 Store refrigerated food A Potable water <br />0 Store dry food/supplies 0 Overnight parking ti Vehicle wash <br />I. /-U1 CA 13 G ratcLa ,hereby state that the information I have provided is current, true and <br />2-4 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 shall 'fy the EHD immediately. <br />Signature ----- Date tfl I '2- 9 ---- 1._ <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 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgtehd <br />Date <br />•