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jN ;:jQAQ(jIQ Environmental Health Department <br /> ;e k4, --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.com leted by APPLICANT <br /> Business NameL'I A 7(,(a 2)(11of Lie.Plate#C�L�k <br /> Owner/Operator Name .- <br /> Business Mailing Address 1i7 Z-V <br /> City C/01 f { 1 r` State�Zip i ) Bus. Ph.::2? ` ;-)U Aft. Ph. <br /> I, 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 /> Signature Date�'� <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR -- <br /> Commissary Name LA C(-) CYv c C� fA FA# <br /> Address ogglop E `ArA,(c ,,A t_as.M Bus. Phone aOC1 nnL� �j�� �l S 70 <br /> City 0�0(''y_ c_ Zip X15 205 Owner/Operator C 1n: n t1 toe_±± <br /> Check all appropriate services provided: <br /> Wastewater disposal Er/3-compartment sink 0 EI trical hook-ups <br /> ' olid waste disposal E3 Food preparation �T let and handwashing <br /> 0 Hot& Cold water for cleaning 1�3 /Sto�a refrigerated food iH P able water <br /> El Store dry food/supplies GYOvernight parking Vehicle wash <br /> 0 5 9� V- , 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 t4q compl with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary out jre sh I notify the EHD immediately. <br /> II J i <br /> Signature Date <br /> u <br /> FM 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 952051 T'209 468-3420 1 F 209 464-0138 1 www.sjgov-orglehd <br />