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Environmental Health Department <br />REHS Signature.Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420] F 209 464-0138 | www.sjgov.org/ehd <br />SAN JOAQUIN <br />COUNTY <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 <br />BusinessName||\C0\ SlNAWKlic. Plate#301 MJ. <br />Owner/OperatorNameLWS LOpEZ LU 6) A______________________ <br />Business Mailing Address RESl p--E _ ___ __________________ <br />city S C jQ b N State 6 A Zip 'Z ^2/5 Bus. Ph.Alt. Ph. <br />i, EVI SA-LOPE?. MO, 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 />Sig nature Date_ <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 0 h/l /V Lb S A T~)?-V C K- L 1 ________________ <br />Address HQ 5 . UN W N ST .Bus. Phone/ Z j 7^^' I <br />City Zip ^7,$'7 0 Lp Owner/Operator Pp/Wf EA Q <br />Check all appropriate services provided: 0 V P P (V I L] ) 7 ' <br />yj Wastewater disposal X 3-compartrnent sink Electrical hook-ups <br />Solid waste disposal Food preparation \ Toilet and handwashing <br />Hot & Cold water for cleaning Store refrigerated food X Potable water <br />A Store dry food/supplies Overnight parking ' X Vehicle wash <br />I, 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 />------------------------------------------------------------------------------ ---------------------------------------------------------------------■------------------------------------------------ ■ ....................... •• •- ■ ................................ <br />commissary owrtei <br />SiqnatureT_C<<- <br />conditions of this agreement, or if this agreement is modified or cancelled, the <br />immediately. <br />________________Date <br />3. Totfe^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 />l y^lAA TTYA <br />operator fails to compb <br />srshal