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SANdOAQUIN <br />—COUNTY-- <br />Greatness grows here. <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility 6 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 />Business Name )4,, 4vi Za , prep/ ;714 <br /> <br />Lic. Plate # 9R/1`//111 <br /> <br />Owner/Operator Name /l1tYi4 60.4441.4.1pe_ Rain" <br />Business Mailing Address /7'O.AefTe-4-50., $4 <br />City 51-och iorl State CA- Zip (157.06 Bus. Ph. Alt. Ph. <br />I, Attr:4 6uo1 ci4ivee_ 84 rrt) n , 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 s. <br />Signature Date I( <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name La Corni5oria 1tt0c154o <br />Address lit 5. -3:PI 31-ra-17. Bus. Phone 70 41-33 S -3‘63 <br /> <br />City /40451-o Zip 53 5l Owner/Operator /146,A vi s-c.A/Z <br />Check all appropriate services provided: <br />El Wastewater disposal <br /> <br />O 3-compartment sink <br /> <br />O Electrical hook-ups <br />13 Solid waste disposal <br /> <br />O Food preparation O Toilet and handwashing <br />Hot & Cold water for cleaning O Store refrigerated food <br /> o Potable water <br />Store dry food/supplies <br />O Overnight parking O 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 notif e EHD immediately. <br />Signature d /". Date // <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 Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I 1 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />FA# <br />I, A40 ,14 Luis - Cr-0Z-