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SAN--J O A Q U I N Environmental Health Department ' COUNTY------ Greatness cgroi vs here. COMMISSARY AGREEMENT Mobile Food Facility ,";. Caterer Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. 1. To be completed by APPLICANT Business Name 2�� Lic. Plate# q N Owner/Operator Name �C �C C,V I� Business Maillitinng��Adddress [r q)?.�, c F'R-�WA C Ps 1\A IF City STR lJ 1 State(P�Zip 'Bus. Ph.(-2-0) 'b 00 �15 It. Ph. I, E VK. K(A ,I , I N r ,hereby state that the above information is current,true and correct to the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the commissary is di s tin ed,the permit holder must notify the EHD. Failure to notify this office may result in permit revocation and p a �- Signature Date D Gc - 1 }�3 2. To be co !ped by COMMISSARY OWNER/OPERATOR Commissary Name V N�� yIO N CR 1 1� KIN TI—idt"I� A � 11S:E; IN Address—I10 5 - V ION RF Bus. Phone �}2ori A -) q City S�C.�-UZip gS20(P Owner/Operator S I F-f 1 Y E Tj P ftN$C) Check all appropriate services provided: Wastewater disposal 0 3-compartment sink 0 Electrical hook-ups Solid waste disposal 13 Food preparation Toilet and handwashing Hot& Cold water for cleaning ® Store refrigerated food Potable water j Store dry food/supplies 13 Overnight parking 77!1 Vehicle wash I, e i � hereby state that the information I have provided is current, true and correct to the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the commissary ow r s II notify th D immediately. Q Signature Date ��e c �o i 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. The commissary is located in County. The above food facility meets the commissary requirements in California Health & Safety Code. The above checked services are available at the above commissary. Please notify EHD if the status of their operating permit changes. REHS Signature Date 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464.-0138 1 m,vw.sjgov.org/ehd