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SAN JOAQUIN Environmental Health Department <br /> —COU [NJ TY--- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 4 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 Lic. Plate# IJJOULnw1 LP <br /> Owner/Operator Name CTL M 2 ozc— <br /> Business Mailing Address 1 10 i e . 1-1 a.r(/IlA UA . v 14I e lJ <br /> City- c\.LkM StatefZip 9 S J Bus. Ph. 2(7G •f)K.. S,;Lg2 t. Ph.2 fi, _c;CjU. It)i <br /> I, l..j')p tT Cwt I e L Hf hereby state that the above information is current,true and correct to <br /> the best of my knowledge and agree o 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 p naltie . <br /> Signature Date I I 5 a-U <br /> 2. To be c m eted by COMMIS Y OWNER/OPERATOR <br /> Commissary Name E I -:Fr ,, I FA# <br /> Address_ I Ml F. tj 0J,( r1n U" S Ii Bus. Phone 21)5 • Flo S. Sa-3-7 <br /> City S4-nc.U'_T/ln Zip—s 2 O Owner/Operator 1,j&e t- Ga/\2-C-11'2- <br /> ref cuzG <br /> Check all appropriate services provided: <br /> Wastewater disposal � 3-compartment sink ❑ Electrical hook-ups <br /> tj Solid waste disposal LFI Food preparation Toilet and handwashing <br /> u Hot & Cold water for cleaning i�Store refrigerated food Potable water <br /> Store dry food/supplies ❑ Overnight parking [3 Vehicle wash <br /> _LIQ <br /> La8jKX WQ M,04 lE - , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge, d 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 /> comMleted <br /> fy t e EHD imme ' ely. <br /> SignDate I� I S �a U <br /> 3. Tob the ENV;H H unsdicton otatside.of•:San Jo'a 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 wvAv.sjgov.org/ehd <br />