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U-11, , Business Name -2 <VVA_L', C(1'. 7-Tc r Lic. Plate # <br /> z <br />1. To be completed by APPLICANT <br />SAN JOAQUIN <br />--- COUNTY <br />Environmental Health Department <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 />Owner/Operator Name <br />Business Mailing Address b) (pH* ( tS. GI 2_ 3 L'_tot,r6 <br />City - StateCiWZipric---V((_; Bus. Ph. 2.L'i • Alt. Ph.0 <br />I, k: (;,- (0-C rk , 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 (END) 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 Penal 'es. <br />1 Signature /6-T,7 Date c-) Zc) <br />ompleted by COMMISSARY OWNER/OPERATOR <br />Commissary Name Cc CY\ rh c-SCL <br />C,c',l1(( <br />Zip ct Z <br />y FA# 7r, - 3 - s <br />uLa_. Bus. Phone Z09- 7, -Z S <br />YO Owner/Operator A <br />Address 31) <br />City L•k _--,c4 <br /> <br />2. To b‘ <br />Check all appropriate services provided: <br />Wastewater disposal -K: 3-compartment sink !=:i Electrical hook-ups <br />Solid waste disposal E Food preparation '..A:- Toilet and handwashing <br />--'7 Hot & Cold water for cleaning 17i Store refrigerated food S.: Potable water <br />Store dry food/supplies 7 Overnight parking ;?c. Vehicle wash <br />L C-7 , hereby state that the information I have provided is current, true and <br />correct to the best of my krtowledge, 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 tify th EHD i diately. <br />Signature — l'7''- - 4 _4-"--------_,-oe-: 7 Date 3 • / - 20(!cl <br /><"- <br />3. To be completed by the EAV HEALTH jurisdiction 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 Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd