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SAN J O A Q U I N Environmental Health Department <br /> ----COUNTY-- <br /> Gratne5s <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility s 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 ,J <br /> Business Name Lic. Plate# <br /> Owner/Operator Name AiwLee- De ti & 4 l/ C;Lr&U5 l�eA��Qq <br /> Business Mailing Address 100� Dr, <br /> City1'^" � cQ, State QA- Zip ` 57,44- Bus. Ph.(�a)�_q-9 23L(O Alt. Ph. LZo°t)to01-yctlS <br /> I, (L,Jt arGv5 DCA-'Z& , 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 Date 10 jSe.LSZ <br /> T <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name s FA#1 <br /> Address (070 Bus. Phon Z�(0dl 1 2ZyO3?��{ <br /> City l .0,l Zip G�2'40 Owner/Operator f�/W �IQ <br /> Check all appropriate services provided: <br /> Wastewater disposal ® 3-compartment sink O Electrical hook-ups <br /> p Solid waste disposal ® Food preparation ® Toilet and handwashing <br /> ® Hot& Cold water for cleaning ® Store refrigerated food ® Potable water <br /> ® Store dry food/supplies Wvernight parking ® Vehicle wash <br /> I, M ( )a 7-}P , 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 owner shall n ti h EHD immediately. <br /> Signature Date Ik �aZ IzZ <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San 46a uin 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />