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Environmental Health Department <br />Date <br />SANJOAQUIN <br />-----COUNTY------ <br />Greotness grows here. <br />1868 E. Hazelton Avenue | Stockton. California 95205 | T 209 468-3420) F 209 464-0138 | www.sjgov.org/e <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 /> <br />pTro be completed by APPLICANT I <br />Business Name_FR>VThS P I CI 0 5 A 5 <br />Owner/Operator Name A R | t L ()CH QCH <br />Busi n ess, MailingAddres s^o^)2_ tS- V\JlL LC W <br /> City£R) ClODNstatelAziP_M2^Bus. H 4-U67jlt Ph. <br />*■-—-p) Q F2 I—Lfc L—Q.Q H H~, hereby state that the above information is current, true and correct to <br />my knowledge and a9ree to utilize my approved commissary in accordance with California Health & <br />atety 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 penalties. <br />Si9nature-----------Date , 2C1C <br /> [2. To be completed by COMMISSARY OWNER/OPERATOR ] <br />Commissary NameVhH^N j |2 Uc|C _______________ <br />_--------------------------------------------------*___________Bus. Phone [ zZAj ~ S <br />X Hot & Cold water for cleaning <br />Store dry food/supplies <br />i. VFSIKA TifSA <br />Lie. Plate # G A R. | <br />* Silh <br />Address nn S1~ Bus. Phone S~q <br />City... ^>77? CA-TZ? Zip \ 5LC?Io Owner/Operator Mt? ]~] <br />Check all appropriate services provided: <br />-^Wastewater disposal . -^S^3-compartment sink <br />Solid waste disposal X Food preparation <br /> Store refrigerated food <br /> Overnight parking <br />. hereby state that the information I have provided is current, true and <br />OP~f.tOr fa'IS t0 comp,y with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> Date 2^, 10 21? <br />[ 3. To be completed by the ENV 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 <br />Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />Vehicle wash <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />commissary owner shall notify_the-EHD-immedfately. <br />Signature