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SAN. J OAQ U I N Environmental Health Department <br /> --C O U N T Y------ <br /> Grec here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility v 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 KA N( SOL MC ICI}M F&©(j Lic. Plate# 7 (16 Y11%6 <br /> Owner/Operator Name JZ-5U5 6 dUTP, )b Rll/eO <br /> Business Mailing Address �I Z, 2 L-14 <br /> City S7—oCrIOstate CA Bus. Ph. Alt. Ph. <br /> 1, �� `-L(,j_ �, It 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 Environment I 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 S 2 ©2 e_-) <br /> 2. To be completed b COMMISSARY OWNER/OPERATOR <br /> Commissary Name �t t o C ' / DJ CxCz d Tc'A FA# <br /> Address 17 ( 7 1V(6 41 S K Bus. Phone <br /> City ( Zip Owner/OperatorR [ __�?L 'Z)6 <br /> Check all appropriate services provided: / <br /> ff Wastewater disposal la/3-compartment sink M" Electrical hook-ups <br /> Solid waste disposal Food preparation WToilet and handwashing <br /> � Not & Cold water for cleaning estore refrigerated food t�Potable water <br /> T <br /> Store dry foo' Su lies Overnight parking Vehicle wash <br /> CG <br /> I' ��1 / /R", , 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 own 9hal o ' D im ediately. _ _ <br /> Signature Date `-S) 1-2 <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 4.64-0138 1 www.sjgov.org/ehd <br />