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SAKdOAQUIN Environmental Health Department <br />—COUNTY-- <br />Greatness grows here. <br />�ssA <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 />11. To be completed by APPLICANT <br />/7 I <br />Business Name VAII A Food Comfao y Lic. Plate u� S -9i <br />Owner/Operator Name�G���t^ �t2 4(dq <br />Business Mailing Address 29 to3 A 4�"�Yzl� <br />City -S fV� State � Zip '71'24�' Bus. Ph�Ov')9&y' PD Alt. Ph. <br />; <br />I. i /a!2 /4 6' fzxW lq _,hereby state that the above information is current, true and correct to <br />the best of my kno ledge 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 r77" — Date #OP' It-07� <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name RAR 601 4rIlGKINQ "IRUWk CEN10 <br />Address 1717 S, ULAle4d IT Bus. <br />Check al appropriate as p or priate services provided: / b 6-111"l-lt <br />ff'wastewater disposal ® 3 -compartment sink <br />Z Solid waste disposal <br />E3 Food preparation <br />z <br />L <br />O Electrical hook-ups <br />Ed"Toilet and handwashing <br />M'Hot & Cold water for cleaning <br />13 <br />Store refrigerated food <br />C11"Potable water <br />O Store dry food/supplies <br />C] <br />Overnight parking <br />M Vehicle wash <br />I, fi I yRAn U , hereby state that the information I have provided is current, true and <br />correct to the best of my knowledge, 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 ow r sh ti the E immediately. <br />�j� / G <br />Cinnnfi,ra / it �(.�--✓ Date ///�'� � �' <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin Ca <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 Signatu <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />