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SAN 10 A Q U I N Environmental Health Department <br /> Y., COUNTY ._._ <br /> Greotness 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 com leted by APPLICANT /� <br /> Business Name l 1nZ '&OXC'ggj l)el ; Lic. Plate# _1 U V 1j_Z--T <br /> Owner/Operator Name A I K-Lee, D-P_Ai,� V larGuj _.eAke�A <br /> Business Mailing Address 100C( Iii r�woy Q �r. <br /> City �cQ, State QA Zip 95Z4 Z Bus. Ph.Pk)6}9 23LI O Alt. Ph.� -1 601-9'M lb <br /> I, i'✓IarGvS DZj e& , 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 (01/Ze/2Z <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name rCrA FA#1 <br /> Address (070 � ( t�Q�{rE� � Bus. PhoneWq 1 ZZy PT-L� { <br /> City 1 l Zip Owner/Operator ` xk (�(�N)[1�_C-70 C-r1�/ <br /> Check all appropriate services provided: <br /> A Wastewater disposal 0 3-compartment sink 13 Electrical hook-ups <br /> E3 Solid waste disposal 0 Food preparation 13 Toilet and handwashing <br /> O Hot & Cold water for cleaning 13 Store refrigerated food 13 Potable water <br /> 13 Store dry food/supplies Wvernight parking O Vehicle wash <br /> jA AR A-e()2 hereby state that the information I have provided is current, true and <br /> correct to the best of myn�ledge, 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 Ilk It C) IZZ <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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />