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PI? os- 4g14 � <br /> SAN JOAQUIN Environmental Health Department <br /> --COUNTY— <br /> .. - Grcuu,r s grows here. <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 Lic. Plate V � — <br /> Owner/Operator Name S n kk <br /> Busine s Mai'ng Address t 'l <br /> Ci �Stat Zip us. Ph. V / U I Alt. Ph. <br /> I, hereby state that the above information is current,true and correct to <br /> the best of my knowledg d agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Jawdouin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is disconti e ,t permit holder must notify the EHD. Failure to notify this office ay result in permit <br /> revocation an p alt s. <br /> Signature Date V 1 <br /> 2. To be completed by COMMISSARY OWNER/OPERATO <br /> Commissary Name <br /> ff�� � n F"A# <br /> Address le72A Bus. Phonejt)oj <br /> CityL - U Zip�O Owner/Operator LVFS 1"r�✓'�/ G 2r�t <br /> . <br /> r <br /> Check all appropriate services provided: LOVE'S TRAVEL STOP#538 <br /> 1� Wastewater disposal e3-compartment sink ❑ I &1W <br /> ON ROAD <br /> ❑ Solid waste disposal ❑ Food preparation ❑ Toilet and handwashing <br /> ❑ Hot&Cold water for cleaning ❑ Store refrigerated food ❑ Potable water <br /> ❑ Store dry food/supplies Overnight parking ❑ Vehicle wash <br /> I, , 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 tomply with the 99nditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary o +er aWnotith HD immediately. �} �j� ISignature I Date tot ;ilJ� <br /> 7)1 <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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />