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SAN JOAQUIN Environmental Health Department <br />COUNTY— <br />u;cotness grows 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. To be completed by APPLICANT <br />Business Name i4kAAy S L- I,C- Lic.Plate# <br />Owner/Operator <br />Business Mailing <br />city Lad, <br />State CA Zip 9f242 Bus. +13(_Alt. Ph <br />1,A m 1 3 til B7X�2 , 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�t. <br />_ . 2_ '1/ —.7 '1 <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name BLF/Vn F�df Il%Ztlyk FA# <br />�L <br />Address r�� S . sc�{c�� s r_ r3 Bus. Phone 2103 <br />city%% Zip Q Owner/Operator D <br />Check all appropriate services provided: <br />E3 Wastewater disposal 13 3 -compartment sink O Electrical hook-ups <br />)g <br />Solid waste disposal <br />E. Food preparation <br />_ <br />TdRet and handwashing <br />M <br />Hot & Cold water for cleaning <br />10 Store refrigerated food <br />E3 <br />Potable water <br />C9_ <br />Store dry food/supplies <br />M Overnight parking <br />O <br />Vehicle wash <br />I, U 0L , hereby state that the information I have provided is current, true and <br />correct to the best of my know) dge, 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 el( all notify the EHD i ediately. r_ <br />Signature%) Date2 <br />13. 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 />