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- C0 2100t7o _1 -1 9 SAN J OAQ U I N Environmental Health Department e , COUNTY RECEIVED Greatness grows hare. COMMISSARY AGREEMENT MARS 0 4 2026 Mobile Food Facility ♦ Caterer ENVIRONMENTAL HEALTH DEPARTMENT Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. CTo be com feted by APPLICAN�T Business Name��-D L r«" O I V gl A Lic. Plate#� 4 Y V 2 Owner/Operator Name H(qNhC,1 0 V I LL - E L I S,FR Business Mailing Address , 1f1p N• O L II V E A-VE City's'm State (Azip ►I S 215Bus. Ph.( 2,09 1 1 1 1.- 196Y Alt, Ph. I, 1 GNIN'O�I � If_� 1 , 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 San Joaquin County Environmental Health department (EHD) requirements. If the use of the commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit revocation and penalties. 1 Signature Q t\ �AC n \ i - Date 0L2�) ln,-i-1 -2-r)�r� 2�To be completed by COM6NMMISSARY OWNER/OPERATOR Commissary Name I, � T VL CEI I ft�_ Address V ) 1-1 UNION ST sus. Phonel 'LU'119 City�STD CK—TVI_V _Zip g5JU V Owner/Operator f4y � _ TI PLADO Check all appropriate services provided: Wastewater disposal ).(3-compartment sink ❑ Electrical hook-ups Solid waste disposal "' Food preparation P Toilet and handwashing Hot & Cold water for cleaning ❑ Store refrigerated food Potable water ❑ Store dry food/supplies �^ ❑ Overnight parking Vehicle wash G I,_ J I KA _10 J A hereby state that the information I have provided is current,true and correct to the best of my knowledge, and meets the California Health &Safety Code requirements. if the food facility operator fails to comp wi . ns of this agreement, or if this agreement is modified or cancelled, the commissary ow 11 noti e im diately. 1 Signature __ Date �3 Q P L3. To be co p eted by the ENV HEALTH_jgr dictior� outside of San Joaquin Co. The commissa ocated 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 bate 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.orglehd