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Environmental Health Department <br />TV VA Date <br />Date <br />REHS Signature.Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />YES'! k-A SfiSK <br />correct to the best of my <br />operator fails to comply W <br />commissary ownershett^SotrF <br />Signature <br />SANJUAOUIN <br />------COUNTY— <br />^Electrical hook-ups <br />^Toilet and handwashing <br />Potable water <br />^Vehicle wash <br />011 n I <br />3. Tojfe^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 />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />I 1. To be completed by APPLICANT <br />Business Name APNA Pl/A/JA&l PHfi&A- __Lie. Plate# ^jTJ \l? ? 0 S <br />Owner/Operator Name B A L V\/ | N D £ S <br />Business Mailing Address, IKH? AVE <br />City|\AM^E6 Astate^Azip^l^l Bus Ph.^D-315 ~ 8^/ Alt. Ph. <br />i. Bftl. , 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 penalties. <br />Signature, Date bzllbllOllf <br />| 2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name UNION 6^MTAa# <br />Address R 11 S- V ST Bus. Phone 20^ 5^11^ <br />City $TD C-^-TZ^N/ Zip Owner/Operator /V 17 <br />Check all appropriate services provided: ' E I^N 16] T <br />Wastewater disposal 3-compartment sink- <br />Solid waste disposal X. Food preparation <br />Y Hot & Cold water for cleaning i V Store refrigerated food <br />Y Store dry food/supplies Overnight parking <br />I. YES'| K-A SOSK ' , hereby state that the information I have provided is current, true and <br />rwledge, and meets the California Health & Safety Code requirements. If the food facility <br />e conditions of this agreement, or if this agreement is modified or cancelled, the <br />nelEHD immediately.