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v3 <br />SAN JOAQUIN <br /> <br />Environmental 1141aith Department <br />COUNT <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 />I 1. To be completed by APPLICANT <br />Business Name tiVP0 3 VVi q S <br />Owner/Operator Name INA eVILV B 01W,.vs LIG <br />Business Mailing Address ari- F-misi tc ct- <br /> <br />Lic. Plate # ct,;-031 <br /> <br />City bill Jr- StateCt\Zip eic103-2- Bus. Ph. 2-Oti 1.07-SIggliS- Alt. Ph. 2/34 251 <br />Yit9tlitO Pity . 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 pen ti <br />Signature Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Ptivo 4 \NI MO <br />F A# <br />Address te t Cjr <br />Bus. Phone jt 161 71 s.(4 <br />City b(11 Zip 1S1032- Owner/Operator Mbilitida <br />Check all appropriate services provided: <br />Wastewater disposal <br />-d-Solid waste disposal <br />4 Hot & Cold water for cleaning <br />Store dry food/supplies <br />V1 i2t 0-0 MOYIW <br />4 3-compartment sink <br />Food preparation <br />Store refrigerated food <br />Eli Overnight parking <br />, hereby state that the information <br />tI:t• Electrical hook-ups <br />-1ft Toilet and handwashing <br />y. Potable water <br />Vehicle wash <br />have provided is current, true and <br /> <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 owner shall notify the EHD immediately <br />Signature 11 _7\ Date <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in SACOtrae4-iiv CAdJ 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 />RENS Signature /kir/ • aft 71 0 c) <br /> <br />Date <br /> <br />1868 E. Hazeiton Avenue Stockton, California 95205 I 1 209 468-3420 F 209 464-0138 www.sjgov.orglehd