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S A N J 0 A QU IN Environmental Health Department <br /> COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections 9 and 2, if your commissary is located outside of San Joaquin County also complete section 3. <br /> aob� c� 1 Ided b' APPLICANT <br /> Business Name MarjSCOS f4 O ft g�Lr_1L.ic. Plate# <br /> Owner/Operator Name c�:r-e- o -ea L,--.5 <br /> Business Mailing Address 10 y 0 A >M I Z,L vJ CAAA <br /> City k , rr%G eY-% State e,*Zip 9 Bus. Ph. Alt. Ph. 20c {o o3 '-Or(A� <br /> I, P_ a �r-q.e-k C, Qn-rg ,% 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. / `J <br /> Signature R0D 06?1 C Date <br /> —r1 <br /> r r ;To4be cQr j IefiEd Ib COMMiSSARY OWNER/OPERATOR <br /> Commissary Name Lg Co m e-rc,i & FA# <br /> Address 2960 r Bus. Phone 2o4 4(v9 T576 <br /> City A-&� Zip 2CaS Owner/Operator R, 'C'x J(2 <br /> Check all appropriate services provided: <br /> Wastewater disposal V 3-compartment sink ! Electrical hook-ups <br /> Solid waste disposal U Food preparation 1q, Toilet and handwashing <br /> 1, Hot & Cold water for cleaning U Store refrigerated food 1Potable water <br /> la Store dry food/supplies Overnight parking A 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 otify the EHD immediately. <br /> Signature �f Date t 2 s <br /> =��Y, 4Q.�be;c�®h� 'Ietec�''b',;the ENV HEALTH 'uri'sdic�ion outside o� 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 /> 1868 E. Hazelton Avenue i Stockton, California 95205 l T 209 468-3420 i F 209 464-0138 1 www,sjgov.orglehd <br /> 1"20S203o R <br />