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S Q N QQ I Environmental Health Department <br /> —COUNTY— <br /> Greotness ,I c,.,s h=r=. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility a 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 LADHo 7- 60(� Lic. Plate# <br /> Owner/Operator Name jrfA E 1 L eM14 <br /> Business Mailing Address Slo l yqL cou?2r <br /> �y <br /> City 9�k7-0O Stateif/lIZip / 2 Bus. Ph.�O� 619 O19YAIt. Ph. <br /> i, 54!5A Al zr� L M' � 4r Ps,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 nalties. <br /> Signature Date �"S Zo >D <br /> 2. To e completed by COMMISSARY OWNERIOPERATOR <br /> Commissary Name S-1r0Ca o?ll r bt)OM»k fteL %cE-Ce0q <br /> Address (430- { WE9,,R Bus. Pho^ne/ -2-07' - �-{ <br /> 3 t S <br /> City S/gQ(TV <br /> U /lJ Zip Owner/Operator e2J'/Ce )10/(Jp;� <br /> Check all appropriate services provided: <br /> Wastewater disposal ®compartment sink 1211"Electrical hook-ups <br /> ® Solid waste disposal Food preparation Er'Toilet and handwashing <br /> E3 Hot& Cold water for cleaning la'Store refrigerated food potable water <br /> O <br /> I, St dryfood/supplies <br /> ® Overnight parking Q Vehicle wash�PC44 C06U YVWf-'L/ <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 ow . r shall notify thhp EHD immediately. <br /> Signature l OA/I �( �j(/1(l1AGfJCti Date <br /> OC 0�3 On b 1 We G d!i i <br /> 3. To be completed by the ENV HEA tside 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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />