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RECEIVED<1, <br />MAY 2 0 2025 . <br />£/H3'7l(O <br />Date Signatu <br />Date REHS Signature <br />s^- <br />Alt. Ph. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />FA# <br />Bus. Phone" "S U <br />Owner/Operator_ XjaiVWcxvn <br />Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />^0 Vehicle wash <br />Wastewater disposal <br />Solid waste disposal <br />yi Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I. I <br />Environmental Health Department <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />SAN JOAQUIN <br />-COUNTY- <br />tTAeatness grows here <br />ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Date y- l^l - z r <br />___________________________________________________________ <br />1. To be completed by APPLICANT _______ <br />Business Name PnmA pldwr' CUC Lie. Plate # <br />Owner/Operator Name pY-UhuS Align KuJw'U Pfcli&Y' <br />Business Mailing Address 53/3 (Swxfss <br />City Stated Zip 4^4Wbus. Phu <br />■. / Al __, 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 />Signatu re <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name YT-PcWa LLC <br />Address <br />CityVM^VO Zip <^53 <br />Check all appropriate services provided: <br />Iji 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br /> Overnight parking <br />, 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 faite to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissarJ owner shall notify the EHD immediately. / <br />y// 9/3-y <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in I I 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.