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SAN�JOAQUIN p, <br /> °> Environmental Health Department <br /> 1:.1kL'�' —COUNTY— <br /> rw.,IF <br /> Greatness gro Ns here. <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. Tobe completed by APPLICANT <br /> Business Name ] �s Clo-rrCzL_S Lic. Plate# LIT f'3 1:3 l <br /> Owner/Operator Name �e Vd'os <br /> Business Mailing Address y900 A/d fg F9 US <br /> city „ State CA Zip qf Z I Bus. Ph. Lo-771-�?730 Alt. Ph. <br /> I, Un rocs 11 H. 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 /> Signature 2 Date <br /> 2. To be cam leted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name SLU<K��YI S jl C7�Ql�•�J�zL A# <br /> Address Bus. Phone 33 La <br /> nom/ //II <br /> City �( DG� G Zip C"2o S Owner/Operator t/FLJZ�i CyI GZ/ /ti r 4 �. <br /> Check all appropriate services provided:: <br /> Wastewater disposal ❑ 3-compartment sink M Electrical hook-ups <br /> • ' <br /> [3Solid wasie disposal [3 Food preparation ❑Toilet and handwashing <br /> C'ltHot & Cold water for cleaning C9 Store refrigerated food ❑ Potable water <br /> ❑ Store dry food/supplies f"Overnight parking ❑ Vehicle wash <br /> I' , 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 /> commissaryo ner shall notify the EHHD i/mmediately. <br /> Signature / <br /> / � L'L `,1 /,I 1 Date G( (7 � 2021 <br /> ; <br /> toCl(t n' <br /> 3. To be com leted b the ENV EALTH uns c fA�Tutside of San Joa in Co. <br /> The commissary is located in n,uanfomra U0205County. 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 />