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SAN JOAQUIN <br />COUNTY - <br />GreotnEsi pov,5 here. <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 />lbe Completed by APPLICANT <br />Business Name AA ,soos 'Frescos. i-sd-i'69 114 Q -zrei-icauc. Plate # e rY) S56 <br />Owner/Operator Name (2._c4..c.4.e..- I C-T el7 OAR C <br />Business Mailing Address 100 4k Ifs)exi Liheler) CA 61S-2- <br />City Lc VA, c-(e r) State e. Zip 4S-Z3 Bus. Ph. WY( 0 3 Oce 3(o Alt. Ph. <br />I, 2 (Lc0.-eI a Les , 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 L. <br />be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Lot co mer c, FA# <br />Address 2-`1 0 f • k-CA.Y0 11.01 WO-1 Bus. Phone ;2-09 Litr; - c/C (0 <br />City Skvc ftko,n Zip SP Owner/Operator6-1V-' " ne-t+ <br />Check <br />- <br />Check all appropriate services provided: <br />n'e Wastewater disposal <br /> <br />P'3-compartment sink <br /> Electrical hook-ups <br />El Solid waste disposal <br /> <br />O Food preparation <br /> 13 Toilet and handwashing <br />12-Hot & Cold water for cleaning <br /> O Store refrigerated food <br /> <br />0 Potable water <br />0 Store dry food/supplies <br /> O Overnight parking <br /> 0 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 cancelled, the <br />commissary owner shall notify the EHD immediately. <br />Signature Date — <br /> <br />a 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 <br />pkos2L9soi <br />2 c_ <br />I, 1--\-,k19-4AcCt-80CA--c