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Environmental Health Department <br />Date <br />P(225<»S© <br />SAN JOAQUIN <br />------COUNTY------ <br />Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />^Vehicle wash <br />: current, true and <br />If the food facility <br />or cancelled, the <br /> Date S~ZO-ZS_______ <br />LTI^jafisdlcI^ outside of ^an doaquin Co,- <br />----------County. The above food facility meets the <br />above commissary. Please notify EHD If tTe^tuToTheToTerabng ^t ctn^s. <br />REHS Signature <br />1868 E. Hazelton Avenue I Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 lwww.sjgov.org/ehd <br />3-compartment sink <br />O Food preparation <br />O Store refrigerated food <br />Overnight parking <br />----------- hereby state that the information I have provided is <br />id meets the California Health & Safety Code requirements. <br />^ons of this a9reement, or if this agreement is modified < <br />oiyi icuui e /■ L _________ <br />3. To be completed by the FNV HEALTI <br />The commissary is located in <br />commissary requirements in California Health & Safety Code. <br />feaUo FA# <br />Bus. Phone <br />Owner/Operator O <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Ccmpfete 2. 3 <br />■ 1--.T° be completed by APPLICANT <br />Business Name---------JfttDS bgVTA LLC L ir nht- . <br /> Owner/Operator Name--------- ------------------------------------------------------------------------------------------------------------ <br />Business Mailing Address.' <br /> <br /> uT^7^T^z*’-3sa^Bu*- Ph-ta£tea=im«. pu^pyn-bs <br />commissary is discontinued, the permit holder must notiN IhS PHr T" . ’ ^uiremente. If the use of the <br />revocation and penalties. he EHD’ Failure to notify this office may result in permit <br /> Si9natUre^-^M^=_________mpC______________S- <br />;~2^To;be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name CoVVW\V&(j>Ai <br /> Address.__35S~k) GoUd 4W <br />city___tpdT___ zip TS2MD <br />Check all appropriate services provided: <br />Wastewater disposal <br />Solid waste disposal <br />H^Hot & Cold water for cleaning <br />O Store dry food/supplies <br />i._ tofWiido <br />correct to the best of my knowledge, <br />operator fails to comply with the co&i <br />commissary own&j shall notify th^ EHD <br />Signature