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SAN JOAQUIN Environmental Health Department <br />COUNTY— <br />COMMISSARY <br />OUNTY— <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ 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 n I <br />Business Name L L -TKO SY �- Lic. Plate #�T v Sccl Q1 <br />Owner/Operator Name In N�09;&5 'e- �Do <br />Business MailingAddress19-�?q WPL-?6Le7 D - <br />Cityl"��`�S' V StateCPr Zip�Bus. Ph.�b9• C,18' 3SS3 Alt. Ph.65na 1% 1-4-$S� <br />I, A mpe-e S Got, 6tpep6 , 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. c /� l <br />Signature_ 4 &'e- -) S" Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 24 4.d ;Sar'c ,4�54V FA# <br />Address I l t S. ?{K 5i cm4 Bus. Phone Poq) 338-366 3 <br />City A4CAes+o Zip 95351 Owner/Operator 69/a/ $�ornyc Ccw+n; ssar+f <br />v <br />Check all appropriate services provided: <br />® <br />Wastewater disposal <br />13 <br />3 -compartment sink <br />0 Electrical hook-ups <br />13 <br />Solid waste disposal <br />® <br />Food preparation <br />® Toilet and handwashing <br />m <br />Hot & Cold water for cleaning <br />0 <br />Store refrigerated food <br />0 Potable water <br />M <br />Store dry food/supplies <br />la <br />Overnight parking <br />0 Vehicle wash <br />I, Mark Luis -&v , 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 ow091 shall notify the EHD immediately. <br />Signature <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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />W053 <br />