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SANJOAQUIN Environmental Health Department <br />09)4s. <br />--COUNTY <br />Greatness grows here. <br /> <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 />To be completed by APPLICANT <br />Lic. Plate # 4V (a--(0 0 Business Name 17A.TTF/A S 'I A C C <br />Owner/Operator Name t V t 0C. r- <br />Business Mailing Address 2 t3 kfl fO D <br />City 1) StateLA Zip °24(-) Bus. Pha°1)ef)25-- q_c/ e Alt. Ph.(gg)) 2-40- -tiS 3 <br />I, P2-I r\ I fk , 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 Envir.nmental Health Department (EHD) requirements. If the use of the <br />commissary is e ,:continued, the permit h. must notify the EHD. Failure to notify this office may result in permit <br />revocation -rf/nalties. <br />Signatury; 546 <br /> <br /> Date c42-'112-4 e#L) <br />To be complet - by COMMISSARY OWNER/OPERATOR <br />Commissary Name C,OMAVS-A-V A Z TE c---A FA# <br />Address Co 2_0 S 5A-C viEWT-0 r Bus. Phone( cl) '2 <br />City (A) I Zip (1 Owner/Operator R avAco (C Ac /NJ-A(1 exc«a <br />Check all appropriate services provided: <br />qi Wastewater disposal <br />picSolid waste disposal <br />& Cold water for cleaning <br />0 Store dry food/supplies <br />0-3-compartment sink <br />Food preparation <br />Store refrigerated food <br />EVOvernight parking <br />14 Electrical hook-ups <br />tar Toilet and handwashing <br />121: • Potable water <br />Er Vehicle wash <br />correct to the best of my-knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />e0C\N\t----ic , m hereby state that the information I have provided is current, true and <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall noti ,the EHD immediately. <br />Signature /73//f, <br />3 To be mpleted 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 Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I 1 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />2 <br />Date Os ao/zti