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SAN JOAQUIN <br />—COUNTY - <br />Environmental Health Department <br />r <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 />To be completed by APPLICANT <br />Business Name L OLNNDN Lic. Plate # 5155 <br />Owner/Operator Name AL 1 CI I mogALEs - cogoNApo <br />Business Mailing Address 39 /el get.LEview <br />City S.71) Gia-uni state_cLzip452010 Bus. Ph.01)11(9/5" (01.1 /Alt. Ph. <br />I, IN )C I is, MoiLALf5_, 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 />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name UNION (ATM Nei GOMMISSAIEY liepU4iLINC-7 <br />Address 1111 UNION 51 Bus. Phone ('2O' 1115 - 5 tillo <br />City 511) (J4-11) IV Zip 1S7 0 lp Owner/Operator P-OS 1 gEN E -n gpcDo <br />Check all appropriate services provided: 1 i OV 12- N I Ci HT" <br />)4. Wastewater disposal )$. 3-compartment sink y Electrical hook-ups <br />; Solid waste disposal ,.,Food preparation 7 Toilet and handwashing <br />Hot & Cold water for cleaning 5tStore refrigerated food <br />5? <br />4 Potable water <br />)gi Store dry food/sugplies pt Overnight parking tytt Vehicle wash <br />I, S I !LIN r -11P-A Db , 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 er shall notify the immediately. • <br />Signature Date 01 1 it i losii <br />To be 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 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />1. <br />1705ozt-ILl'-1 <br />Signature ik\ c4nk. e •cc.4.\ S Date 011 St 101-11