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SAN Q Q U Environmental Health Department <br /> COU N TY-- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility a 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 VWS M Os RU rj<.r _T Q t/�KLic.Plate# E(�332VP <br /> Owner/Operator Name pet -6 'n i7 '(`awl Q ' <br /> Business <br /> LMailing Address `120 C • CVI"(k'y- I. <br /> City SI l State OAZipg5-Z-0Y8us. Ph.-I M. 41 OLf-tPit. Ph. IM-LA(A 603 <br /> I, Ott P (AD �Gi(jt�� 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 iscontinued, the,permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocationd n ti <br /> Signatu e Date��/� <br /> 2. To be c leted by COMMISSARY OWNER/OPERATOR <br /> Commissa Name K. oSmot ' &uOw-S, �rFAA�t# <br /> Address - VI�GtI/ ( W 0VQ Bus. Phone div' 1 ' (,(1�nLl -LQ, <br /> city I'("rj zip ` I SZ�� Owner/Operator Del �U I• wwt eA <br /> Check all appropriate services provided: <br /> C3 Wastewater disposal 13 3-compartment sink II Electrical hook-ups <br /> r3 Solid waste disposal 0 Food preparation 0 Toilet and handwashing <br /> 0 Hot & Cold water for cleaning ri Store refrigerated food 0 Potable water <br /> © Store dry food/supplies ❑ Overnight parking 0 Vehicle wash <br /> I, (��i� 1 Y\O 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 /> commis wner shall no ify the EHD immediately. <br /> 5'rgn ure Date. <br /> 3. To be co feted 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 wo-wv.sjgov.org/ehd <br />