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SAN A O AQ U IN 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 /> 1,:-Td.be'cam leted b APPLICANT <br /> Business Name YA4JtS C2VAYSIONS Lf Lic. Plate# <br /> Owner/Operator Name YA,9�4 -N71 A(2- <br /> Business Mailing Address 5-55- W• CA1JC-Ci 13 CX_ <br /> CitytA! � J VtuWState CA Zip15�3A I Bus. Ph. IaOv-l2H-DAlt. Ph. <br /> I, l-'A� -V bA gL , 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 Joaquiq County E vironmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued,t per ' older must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalti s. <br /> Signature Date 2Z <br /> 2. To be conipletiia&by COMMISSARY., OWNER/OPERATOR <br /> Commissary Name Z4 Cor"ooria I000(esko FA# <br /> Address 1911 S. 7" S-i reed- Bus. Phone (�oq) 33$-3663 <br /> City ade5+o Zip 4535 l Owner/OperatorCyl (oma <br /> — <br /> Check all appropriate services provided: / <br /> [2 Wastewater disposal ® 3-compartment sink 13 Electrical hook-ups <br /> 0 Solid waste disposal M Food preparation 12 Toilet and handwashing <br /> l9 Hot&Cold water for cleaning M Store refrigerated food [it Potable water <br /> ® Store dry food/supplies t8.Overnight parking ® Vehicle wash <br /> I, Mair k Luis- Gru e ' 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 /> commissary owner shall notify the EHD immediately. <br /> Signature Date �1d61aa <br /> 3 Tobe com leted�b th&,ENV,HEALTH 'tarisdiction<outside`.of San'Joa dir)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 servicesare available at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> RENS Signature Date <br /> 1868 E.Hazelton Avenue I Stockton,California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br />