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°"s"° SAN JOAQUIN Environmental Health Department <br />—COU NTY--- <br />`,;� Greatness grows beta. <br />r <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Business Name Ska w cAn dq Lic. Plate <br />Owner/Operator Name VGII ula KrJ <br />Business Mailing Address 1133 2 dt,-asDr. <br />City �oGkfaY7 State�-4 Zip 952!0 Bus. Ph. (20R Y914T5�Alt. Ph. <br />I, Ila nr1q k Q d' -c— hereby state that the above information is current, true and correct to <br />the best of my knowledge a5d 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 />02%28/22, <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name S4Gdr--lu') CoznmuAl-f %i4Gyt2n FA# <br />Address 110 611• E! Dorc?do 94 - Bus. Phone ("209 ra08- 5°f56 <br />City &bckh/7 Zip 9£Z02 Owner/Operator Rlmn i rk�t�lL��r {ilio <br />Check all appropriate services provided: <br />Ig Wastewater disposal 0 3 -compartment sink 10 Electrical hook-ups <br />M Solid waste disposal ® Food preparation 10 Toilet and handwashing <br />® Hot & Cold water for cleaning 13 Store refrigerated food R Potable water <br />IM Store dry food/supplies / E3 Overnight parking ❑ Vehicle wash <br />I, Ldontl 4'aAALo 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 togonTly with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary o er §hall notify thejEtp immediately. <br />02 /23 / 22. <br />13. To be completed by the ENV HEALTH jurisdiction outside of San Joaouin Co. I <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 <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 />