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SAN J O A Q U I N 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 com leted by APPLICANT <br /> Business Name TI-2o-?XC�4gz Lic. Plate# qu y.112-- <br /> Owner/Operator Name AlwLee DEAtIt6(11- 4 Mctir&U5 <br /> Business Mailing Address 1009 V-1/�wvy Dr, <br /> City Lvk; State CFF Zip 952L(?- Bus. Ph.(U`OG-49 2340 Alt. Ph.jZo-o bol-y`(`i C- <br /> I, m6t r6y5 DeA;.w-t?a , 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 (t) TOh-L <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name QiaPAi LLG. FA# NS- <br /> Address '—q -(l S, 5�ockfoh 54, 5�iie -T- Bus. Phone (2040 625- I t03 <br /> City Loi r Zip `I S qD Owner/Operator dick Taa(or <br /> Check all appropriate services provided: <br /> E3 Wastewater disposal 13 3-compartment sink E3 Electrical hook-ups <br /> p Solid waste disposal 13 Food preparation 0 Toilet and handwashing <br /> 13 Hot &Cold water for cleaning 13 Store refrigerated food 0 Potable water <br /> ® Store dry food/supplies Fr31; Overnight parking ® Vehicle wash <br /> I, K`CX , 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 s oti a EHD immediately. <br /> Signature Date IV2/29_ <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa 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 />