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S A N.d O A Q U I N Environmental Health Department <br /> —COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT — <br /> Business NameVA C6AA V-1S Lic. Plate# <br /> Owner/Operator Name M, r I,Ia <br /> Business Mailing Address 7fob � Lb 1Q✓�I���R ��� <br /> City ' i'�. State Zip 2S-710 Bus. Ph. Alt. Ph. <br /> c <br /> 1, {f ON p�s,�..� rn per, hereby state that the above information is current,true and corr <br /> ,,yt� ect to <br /> the best of my knowle a 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 /> SignatuDate <br /> 2. Tobe com I - :b. COMMISSARY OWN:ER/OPERATOR-- <br /> Commissary Name_ , FA# 00,27_4 9" <br /> Address_1 (P .2 od 1t1 rel -RA- _Bus. Phone 717-- 96 <br /> City L4:4 -d Zip Owner/Operator *e Vv[— <br /> Check all appropriate services provided: <br /> WWastewater disposal E3 3-compartment sink Electrical hook-ups <br /> ld Solid waste disposal 0 Food preparation Toilet and handwashing <br /> ® Hot & Cold water for cleaning ® Store refrigerated food [j(Potable water <br /> © Store dry food/supplies Overnight parking 1 Vehicle wash <br /> 1, -Vg^ ys , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledgefand 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 own hall no' e EHD immediately. <br /> SignatureDate 7 Z- <br /> 3. Tob com leted`-b thefENV, H:EALTH= urisdiction-autside.,of:San J.o urn-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 Date <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 /> .w A A'. ) 4 d Cy/^i << <br />