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- ,. -SANJ8A0UIN Environmental Health ®epartme�t <br /> —COUNTY— <br /> CONIMQSSARY AGREEMENT <br /> Mobile Food Facility,% Caterer ... <br /> Complete sections i and 2. If your commissary is located outside of San Joaquin Counfjr also complete section 3- <br /> 1. To OS=r6 feted b` APPLICANT <br /> Business Name t' l An P "'r o I Lic_Plate# 93 Z/ 9 1 D'z <br /> Owner/Operator Name Rn4myndo Loge ,1 <br /> Business Mailing Address X33 cr fh��Jco I d i IZ . <br /> City SlOC/MP,n State& p X1$21 ZBus. Ph. Alt, Ph.22!a)g 16(a-300 I <br /> I gerWhdi —�hereby state that the above information is currenLjrue and correct to <br /> the best3kmy knowledge and agree to utl¢e my approved commissary in accordance vM, Carifomia Health t <br /> Safely Code, and San Joaquin County Environmental Health Department(EHD) requirements. if the use of the <br /> commissary is discontinued,th permit er must notify the EHD. Failure to notify this office may result in permit <br /> penalties_ <br /> revocation <br /> Signature Da <br /> T1.770—be com feted.b :COMMISSARY OWNEWOPERATOFg <br /> Commissary Name L A :_S'3 F`.t&a-�f'i f�,i FA# <br /> Address—,qOiC E_ �rrM(A..nc L%i m Bus.Phone DACA ' -'1520 <br /> J <br /> City J�U�,<lt�.n Zip 5 7 ), OwnerlOperator <br /> Check all appropriate services provided: <br /> ,:1 Wastewater disposal 1.3�_compartment sink - i=7`Elgc¢ica(hook-ups <br /> 4olid waste disposal Food preparation ��L -let and handwashing <br /> 'Hot Coldwater for cleaning Store refrigerated food 'X Potable water <br /> Store dna fo d/suppli sp _A�Ovemight parking =f�Vehicle wash <br /> t fli <br /> [, � • , <%r t1/L- .hereby state that the information f have provided is current,true and <br /> correct to the best of my 1 owledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply viih the conditions of this agreemment, or if this agreement is modified or cancelled, Bie <br /> commissary owner shall 5+the EHD r e6ately. <br /> ignatureDate <br /> . — be ma eied by°the EN V HEALTH jurisdiction outside'of San�i�aorsirt O . <br /> The commissary is located in County_ The above food facility meets the <br /> commissary requirements in Califomia 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 /> RENS Signature Date <br /> c868 E_r'a?ertnn Avenue i Stockton,California 02051 T 209 468-34201 F 209 464-0138 1 www4gov_orglehd <br />