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":1PVERUZIN:,a 7t. *C•eSiff <br />SAN JOAQUIN 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 />I 1. To be completed by APPLICANT <br />Business Name LC\ ((/‘ E C cvA- <br />Owner/Oper-atorName 7_-)c) <br />Business yailing Address ("( <br />City Lb 1-\ State C.-14:Zip Bus. Ph.( ?ail) q-Alt. Ph. <br />, 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 pen lb <br />Signature <br />2. To be completed by COMMISSARY <br /> <br />!ID <br /> <br />ERATOR <br /> <br />Commissary Name AZ f e(eL <br />Address 6 70 <br />City L__() 9 <br />5et(v4-, /- Bus. Phone &9(7) 2Z-1/ 3 31/ <br /> <br />Zip 9.' '/d Owner/Operator <br /> <br />Date 6/ <br />FA# <br />Check all appropriate services provided: <br />1714Vastewater disposal IDT 3-compartment sink <br />f2Slid waste disposal <br />& Cold water for cleaning <br />IEZStore dry food/supplies <br />r, Food preparation <br />OStore refrigerated food <br />111Overnight parking <br />ELVElectrical hook-ups <br />Er Toilet and handwashrng <br />0:1,table water <br />la Vehicle wash <br />, 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 cancellecii, t e <br />commissary owner shall notify the EHD immediately. <br />Date — <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 />Signature <br />1868 E. Hazelton Avenue Stockton, California 95205 I T 209 466-3420 F 209 464-0138 s gÔ <br />WD9—i ?-11 21