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S A N ,J O A O U IN Environmental Health Department C O U N T Y-- _,vE RECEIVED COMMISSARY AGREEMENT JAN 10 2024 Mobile Food Facility ♦ Caterer ENVIRONNIENTAL HEALTH DEPARTMENT Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. 1. To be completed `bAPf�PLICANTy fl Business Name C�L l I��j�Tf N I\5 l�G L k S Lic. Plate# q V ( Z Owner/Operator Name J V k N C P� r4-16 C� P PC I P 0S O l- i O BusinessMailing pAddress L D k F-.r ( aI City L� 1 rt t StateCR Zip��j 7��{� Bus. Ph. Alt. I, , hereby state that the above information is current, true and correct to the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & Safety Code, and an Joaqui County Environmental Health Department (EHD) requirements. If the use of the commissary is dis ontir�ued.;' e permit holder must notify the EHD. Failure to notify this office may result in permit revocation and fp na tibs.;- Signature F Date )N N (� i 101 2. To be completed by COMMISSARY OWNER/OPERATOR Commissary NameUN I O N Cf�UP N CA IR06 CC Address 11 ll 5' VN IO N ST Bus. Phone)20 ),t q I u City -f g Zip Owner/Operator p os( t IV C 'I V 7PT_ ptj Check all appropriate services provided: N O S t U P-PPCl E 9E Wastewater disposal IO 3-compartment sink D Electrical hook-ups Solid waste disposal D Food preparation P^Toilet and handwashing .9 Hot & Cold water for cleaning D Store refrigerated food Potable water D Store dry food/sup lies t-D Overnight parking ! Vehicle wash N s a�S hereby state that the information I/have provided is current, true and correct to the best of m knowledge, and meets the California Health &Safety Code requirements. If the food facility operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the commissary owner shall notify the EHD ' ediately. Signature Date i 3. To be-completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. The commissary is located in County. The above food facility meets the commissary requirements in California Health & Safety Code. The above checked services are available at the above commissary. Please notify EHD if the status of their operating permit changes. REHS Signature Date 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd P Q-0-5`'1 �3�;x' 0