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OPQUIN C <br /> °_;, SANAOAQUIN Environmental Health Department <br /> " 1f4; —COUNTY— <br /> F9is' Greatness grows here. RECEIVE® <br /> COMMISSARY AGREEMENT DEC 28 2021 <br /> Mobile Food Facility ♦ Caterer ENVIRONMENTAL HEALTH ALTH <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also compla aE&h3h,,. <br /> 1 . To be completed by APPLICANT Q <br /> Business Name ` , �� Lic. Plate# �� J <br /> Owner/Operator Name SN n _G D <br /> Business Mailing Address <br /> CityD StateCK Zip 0&tb Bus. Ph. - Alt. Ph. <br /> hereby state that the above information is current,true and correct to <br /> the bet of my knowled 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 discontirlued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and pena ti <br /> t%_ <br /> Signature uvq Date Z ILT 2 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name �,�(�l M� ` nCZk P�C� FA# <br /> Address (9Zb ��. u'.ct A tG aA- Bus. PhoneW) 226 -b3 '73'-A <br /> CitZip 052-41) Owner/Operator_%ew Q QNoU A11%1\(M 6(;O14 <br /> Check all appropriate services provided: <br /> UL Wastewater disposal %(3-compartment sink 7K Electrical hook-ups <br /> Et Solid waste disposal 0 Food preparation Pk Toilet and handwashing <br /> $4 Hot & Cold water for cleaning V Store refrigerated food 11 Potable water <br /> PT Store dry food/supplies 1A Overnight parking h-Vehicle wash <br /> I, A--LkeC 1t , hereby state that the information I have provided is current, true and <br /> correct to the best ofi y 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 Gtr/ i' Date <br /> 3. To be com leted bI 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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> f 0-SL►b&A-13 <br />