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SAN 10AQUIN <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility v 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 LA FRUTERIA Lic.Plate# ! S476'75 <br />Owner/Operator <br />Business Mailing <br />CitV5toCKTD9 State CA Zip .J 0 Bus. ph*TC iY'17- U Z-�4klt. Ph. <br />I, SR kn l 1 "6( KP( CD { 1 , 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 />n�ro 9// 9 Z <br />2. To be completed.,p b COMMISSARY OWNER/OPERATOR <br />Commissary Name �{i bA) iM ER/NdYC 2e/- FA# <br />Address 171 5i V1V foN 5T. Bus. Phone 17 F1'j�il <br />City,SnC�TOMr, CA Zip .Owner/Operator <br />Check all appropriate services provided: <br />�MrWastewater disposal U�6-compartment sink EVElectrical hook-ups <br />C <br />z aolid waste disposaP Food preparation (° rToilet and handwashing <br />It] Hot & Cold water for cleaning Store refrigerated food Q,-�'Potable water <br />t,9'Store�ds <br />,roo�/—Lesla Overnight parking Vehice wash <br />Ix z ernnU <br />0 , 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 owners I of EHD immediately. �� <br />Sionature iz� 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 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br />