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SAN --J QAQ U I N Environmental Health Department <br /> COUNTY.__ <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility * Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be Corti leted by-APPLICANT <br /> Business Name I R R I��I� 'c' ��u c�I � A c u ri<hTc Lic. Plate# <br /> Owner/Operator Name 14 (Oltl5eD MLl(L''L) Z- <br /> Business Mailing Address d�� ��/n L / <br /> CityLrgT ffbP State Zip_2L-a--30 Bus. P4gC)3' 636- ()22- Alt. Ph. <br /> I, f2Jfikl� #li;GEu CA Cul"tr R Rez , 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' discontinued, the pemi holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation a penalt'_S. // <br /> Signature Date !I 43 <br /> 2. To completed b' COMMISSARY OWNER/OPERATOR <br /> Commissary Name LUj 10 I C-UtrRi NG 'TRuc'K LEcSTEf- FA# <br /> Address 7 i 7 a a 001 ,5—, � Bus. Phone � <br /> City$T6 G}� pW, CA- Zip ¢5-20(, Owner/Operator RT I (FI?w <br /> Check all appropriate services provided: <br /> Wastewater disposal f"3-compartment sink MlElectrical hook-ups <br /> Solid waste disposal Food preparation Toilet and handwashing <br /> �//,Hot&Cold water for cleaning M�Store refrigerated food 12'Potable water <br /> U Store dry food/supplies M Overnight parking l/Vehicle wash <br /> 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 owner all EHD irpfnediately. <br /> Signature ZZ —� Date �r 13 �` u <br /> 3. To be corn feted 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 />