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SAN JOAQUIN <br /> <br />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 />To be completed by APPLICANT <br />Business Name I— Li C., Lic. Plate # SKR A 1 <br />Owner/Operator Name Le - 3 a.VVki(1 <br />1, <br />Business Mailing Address I .`•-) • 1---A-91, U.) 95-4-0 <br />City917 Ck+PY1 StateC-fiZip 6 2(0 `i Bus. Ph. 21_1-8104-0)-21Alt. Ph. 24- lid.---,58/t95 <br />1, Lc (A. M ITU r-, 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 <br />Date <br />p nalties. <br />b -54 Signature <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 57 CC k<MDtt O Tn-C ;<.tie.AE FA# <br />Address 1,'t EL po tRApc,ç. Bus. Phone (ooq) qqq- zioq, <br /> <br />City STD CACP01.1 zip cl-S"2o2 Owner/Operator LECA-LEL - CDFIP.x) <br />Check all appropriate services provided: <br />El Wastewater disposal <br />fig Solid waste disposal <br />Hot & Cold water for cleaning <br />id Store dry food/supplies <br />&I 3-compartment sink <br />Eg Food preparation <br />Store refrigerated food <br />Overnight parking <br />SI Electrical hook-ups <br />Toilet and handwashing <br />kg Potable water <br />Vehicle wash <br /> <br />LEOI,LE1__ AST LL__t_ , 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 /> <br />commissary o r shall notify the EHD immediately. <br /> <br />Signature <br /> <br />Date <br /> <br />3. 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.orgiehd <br />--Kt-\ op 3g-3