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SAN. -10AQUIN Environmental Health Department <br /> ----C O U N T Y-- <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 /> Business Name L U OQA SOL M6 lCl t� F6)c'b Lic. Plate# 7 (16 9Y U) <br /> Owner/Operator Name TC- 011 P. )� P'0� f} <br /> uS 6' �R <br /> Business Mailing Address ` /� 2 L <br /> City SDCK StateZip 9,'ZIG Bus. Ph. Alt. Ph. <br /> I, �M(,0 � �l/ (�l �rl 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 Envir mental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, the ust notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. _ <br /> Signature Date '2 2 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name l r CCA J 01) <S 7RU6x ���A FA# <br /> Address 17 ( 7 1 6 ST Bus. Phone <br /> city ZG E�1�, LR Zip �.5� Owner/Operator flR7— <br /> Check all appropriate services provided: / <br /> Wastewater disposal 92/3-compartment sink Gd" Electrical hook-ups <br /> Solid waste disposal Q/Food preparation Q'Toilet and handwashing <br /> �P' Not & Cold water for cleaning Er/Store refrigerated food _B"'P' otable water <br /> E Store dry foo�p lies Overnight parking C3 Vehicle wash <br /> C� <br /> I, /Q , hereby state that the information I have provided is current, true and <br /> c ro sect 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 own ha�O ' D,lm ediately. <br /> -2 <br /> Signature Date <br /> 5 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of 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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />