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°F "SAN,,4JOAQUIN Environmental Health Department <br />—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 />1. To be completed by APPLICANT <br />Business Name L195 K0.£Ufls JOERLR6 Lip.Plate# 33gA3B3 <br />Owner/Operator Nam <br />Business Mailing Add <br />City ah ( StateCO Zip tSZ1& Bus. Ph(zcR) 7/2 - ✓`O$ 7 Alt. Ph. <br />I, l� rtly izt�uE (2680w__ <br />6 80I , 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 penalli€s. — / / <br />622-- <br />2. <br />2Z <br />2. To be <br />CommissaryName UN/�N �ftVMNG "rU01, <br />Address/7/7,5. LIA110 5'rkEfT Bus. Phone <br />Cityffc>60W, cii Zip -520L Owner/Operator N7-/1AAda <br />Check all appropriate services provided: <br />[sr Wastewater disposal LB"�3-compartment sink Electrical hook-ups <br />U 'Solid waste disposal ♦Food preparation Toilet and handwashing <br />UHot & Cold water for cleaning WStore refrigerated food /Potable water <br />13/Store dry food/supplies �0�vemjghtE Vehicle wash <br />I, ART /lm.6 enformation <br />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 owner shall notify the FH@ immediately. c <br />Signature G/ Date '5— <br />1 D 12 Z 2Z <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. <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 />