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r <br /> SAN JOAQUIN Environmental Health Department <br /> COUNTY <br /> Greatness 9there. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ® Caterer <br /> Complete sections 9 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 L &S F L O C't-fi Li c. Plate# c5 Q <br /> Owner/Operator Name ItAC-16 £LCR6 6 M 6 4Ji e--S >i2/�ij <br /> Business Mailing AddressGA S A) ° 4A[3OCF—'L ;5 T <br /> CitState_C_LZipC?S,2o5Bus. Ph(lbq) `/05 -'7 `/' It. Ph. <br /> I, oe6 E fl 0C,r�pn ft--S oc cC,#9 , 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�palties. <br /> Signature --Re- Date V, 12o,23 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Named? jjr Qk) C AIC.' �� 7—ku �C )I ' A# <br /> Address ] / ? y!JiyN c,7�[�f'l Bus. Phone()042gk-- 5ylI _' <br /> City -7 ?(K-TOA) 01Zip q1 S.l17 Owner/Operator Aa 71440b <br /> Check all appropriate services provided: <br /> gi Wastewater disposal 0 3-compartment sink 0 Electrical hook-ups <br /> 0 Solid waste disposal 0 Food preparation 0 Toilet and handwashing <br /> 0 Hot& Cold water for cleaning ® Store refrigerated food 0 Potable water <br /> 0' Store dry food/supplies Overnight parking 0 Vehicle wash <br /> 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 ow r shall notify th EHD immediately. _ <br /> Signature /� Date /Z� 2 'Z� <br /> 3. To be <br /> 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 />