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' r # <br /> <br />?klOSLI1c111-1 <br />SAN JOAQUIN <br />---COUNTY-- <br />Greatness grows 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 />To be completed by APPLICANT <br />Business Name C---ak:Nsit•-• Lic. Plate # C.' IR 51/ <br />Owner/Operator Name LAJA- 1-,t- <br />BusiTs Mailing Address 142 <br />/Sy <br />City VA#A-L\—er State 61-\- Zip 615-530 Bus. Ph. -7-oi" .1040..7-3 Alt. Ph. 'Ali: ?--1?/ <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 discont ermi der must notify the EHD. Failure to notify this office may result in permit <br />tcAr, <br />revocation and pe <br />Signature _ Date <br />To be completed by COMMIpSARY OWNER/OPERATOR <br />Commissary Name PAct9;‘,=)5,c1-5 <br />e, <br />FA# <br />Bus. Phone 2-(f/a:4152A- 2-3" 5/-)S79 <br />vrc- \ <br />AddreIs <br />City --N#.4.N.-;•.-E,,AA Zip ci Owner/Operator <br />Check all appropriate services provided: <br />ElWastewater disposal 12/3-compartment sink <br />0( Solid waste disposal Food preparation <br />OY Hot & Cold water for cleaning.0 Store refrigerated food <br />Store dry food/supplies in/Overnight parking <br />El/Electrical hook-ups <br />e Toilet and handwashing <br />potable water <br />E(Vehicle wash <br />, Cs2r-1--) \ , 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 o er s. I no e EHD immediately. <br />Signature <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 /> <br />Date <br /> <br />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