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° - SAN 10AQUIN Environmental Health Department <br /> COUNTY---- - <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 0 Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> eked by' APPLICANT <br /> Business Name S -6e_s TG � VV, Lic. Plate#. 1lJ�S <br /> Owner/Operator Name P In x U u,0 �U L VVI <br /> Business Mailing�AA\ddress qD-2- r11111"Q A 0 <br /> City S'��U�Stat Zipq��� Bus. Ph. 2-OG-14�43Y,6 Alt. Ph.�C'l 2-1I^2 -y-1 <br /> I, e"V CQ.VQ OOH (V, 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 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 penalti q L5 12-3 <br /> Signature Date <br /> 2 n leted b , COMMISSARY OWNER/OPERATOR <br /> fi01 lldoF <br /> Commissary NameC (3Me Ilr FA# <br /> AddressILIqW l�� rl W Bus. Phone CA^ `4`-4C51 0 <br /> City<S� Zip QOwner/Operator �. <br /> Check all appropriate services provided: <br /> Wastewater disposal 0�3-compartment sink MElectrical hook-ups <br /> Eg Solid waste disposal ® Food preparation Ell'Toilet and handwashing <br /> 16 Hot & Cold water for cleaning E3 Store refrigerated food Potable water <br /> O re dry food/ pplies Overnight parking Vehicle wash <br /> I /j�/1// _/VQ — hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledge, and s the California Health &Safety Code requirements. If the food facility <br /> operator f ' to co ply with the co ons of this agreement, or if this agreement is modified or cancelled, the <br /> commiss ry own hall notif Y. <br /> ' 7 Date <br /> Signatur <br /> t> 4 }. eed b the ENV HEALTH jurisdiction outside of San Joa �urn 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />