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SANJOAHIN Environmental Health Department <br />a " —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 />1. To be.com feted by APPLICANT <br />Business Name_{ (i Lf ( A t'V1 V1 G1 LLC Uc. Plate # � WVS ISD i <br />Owner/Operator Name h L4_'VGP,d.('S I` la ref t� <br />Business Mailing Address <br />City S3030k State C�Zip aS122 Bus. Ph. 40y 0 Alt Ph. <br />I, hereby state that the above information is current,.true and conect to <br />the test 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 notiry this office may result in permit <br />revocation and oenaltieS. _ <br />t01502-2 <br />2 To be completed -bCOMMISSARY OWNER/OPERATOR <br />Commissary Name LA FA# <br />Check all appropriate services provided: <br />Qe -compartment sink <br />2_ Wastewater disposal <br />olid waste disposal <br />0" <br />Hot & Cold water for cleaning <br />FW <br />0 Food preparation <br />® Sto refrigerated food <br />'Overnight parking <br />:0 EI cal hook-ups <br />T 'let and handwashing <br />,etable water <br />;'Vehicle wash <br />I, (- AAW1t -- hereby state that the information I have provided is current, true and <br />correct to the best of my knowledge, and the California Health & Safety Code requirements. If the food facility <br />operator f ' to mply with their n :ons of this agreement, or if this agreement is modified or cancelled, the <br />commi ry o er shall nol fy the p lately. <br />Signatu <br />3. <br />be comdetkf by the ENV HEALTH iur sdiction 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 <br />1868 E_ Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 wwwsjgov_org/ehd <br />Wo5n'5-2-N <br />