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SAN J 0 A Q U I N Environmental Health Department <br /> - COUNTY <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 completed by APPLICANT <br /> Business Name La Ts-u d i cl o Qi Lic. Plate#-4U P$GL47- <br /> Owner/Operator Name flee"ej (�6 r i aC a Pp,.r-nanJe:1- <br /> Business Mailing Address q(o� Cme�td Vrsk-& Dr. <br /> City go la- State CA Zip q 536:Z Bus. Ph.(lot) L-I I ct-21-yo Alt. Ph. <br /> I, NeMQ 6o rc(4 Nernande;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 pena)ties. y <br /> Signature Date 6 <br /> 2. To be completed by C MMISSARY OWNER/OPERATOR <br /> Commissary Name Za Aod 5�0 —FA# <br /> Address !21l S. 7+" 5 = Bus. Phone <br /> City Accle-54-0 __Zip G535i Owner/OperatorJ/nom� <br /> Check all appropriate services provided: <br /> El"-Wastewater disposal EY3-compartment sink L3"Electrical hook-ups <br /> (Solid waste disposal EY*Food preparation WToilet and handwashing <br /> C'Hot & Cold water for cleaning 0"'Store refrigerated food EfPotable water <br /> [Store dry food/supplies E Overnight parking 'Vehicle wash <br /> I, 4 61 , hereby state that the information I have provided is current, true and <br /> correc 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 EHD immediately. <br /> Signature - Date 04/26/Z 3 <br /> 3. To be completed by the <br /> yENV <br /> � 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 Datel ��o#� <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 />