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:? of <br />. . <br />t ` SAN JOAQUIN Environmental Health Department <br />,..� . <br />�•ti'_ —COUNTY— <br />: , Greatness grows here. <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 />11.7o be completed by APPLICANT <br />Business Name LACRIt/S GRS'l/iCIV&PIM M*(CA4R Lic.Plate#�'SZ2�39 <br />Owner/Operator Name_TU.LiD entsa dR 4- lsnu !/l SAt47AR_ <br />Business Mailing Address C D D"I ocge /?V <br />CitysI_OCr1'(D(l State G Zip j ,S Bus. PhQdO %1 y-Af33 Alt. Ph. <br />1 /tJr/1�`r�,� 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 andmenalties. 9 <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />CommissaryName U N t 0 a CA 1k-' P N Cx j1ejJe,` e_rAJ? A FA# <br />Address 17 / 7 S . U M (e fd ST, Bus. Phone(g V -e'12 9r - S- /G <br />City Sim CIV Zip �. d 6 Owner/Operator 14fT 'reR/E106 <br />Check all appropriate services provided: <br />lr�vastewater disposal CO' -compartment sink GrElectrical hook-ups <br />13 Solid waste disposal 6�/5ood Fpreparation 111"TToilet and handwashing <br />i'Hot & Cold water for cleaning Ci tore refrigerated food CYPotable water <br />12 Store dry food/supplies p' Overnight parking E l_Vehicle wash <br />1, AST 71—e r a a , 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 own h ti th EHD immediately. -7 <br />Signaturo ' I Date / <br />3. To 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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />