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SAN J O A Q U I N Environmental Heal IS�eparEOtme <br /> —COUNTY— STANI5tAU5C0. <br /> Greatness yrens here. SEP O J 2021 <br /> COMMISSARY AGREEMENT �2� <br /> Mobile Food Facility ♦ Caterer fR0�-tNTAI. <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT t yl <br /> Business Name A't u voA ",o ci ccL , ViceQ Lic. Plate# 1701a-E3 <br /> Owner/Operator Name va o r2 .'C <br /> Business Mailing Address 1-) <br /> City ►:.lo -Jo State CA Zip cks378 Bus. Ph. Alt. Ph. <br /> I, w cs hereby state that the above information is current,true and correct to <br /> the st of knowled 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 discontin4ed,th permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalti <br /> Signature Date 00, 100d -7-C>-T-1 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name /-Z -� ,ti5ae-A /"1�,0,4sk FA# <br /> Address -7w*'' Slrv6Bus. Phone (a43)3313- X63 <br /> City /1' o&&� o Zip 15351 Owner/Operator 6old S{n7:� Lo+r+ iSSv �itC_ <br /> Check all appropriate services provided: <br /> [IlWastewater disposal Q'3-compartment sink 13'Electrical hook-ups <br /> p'solid waste disposal 13' Food preparation CF-Toilet and handwashing <br /> 9'Hot& Cold water for cleaning Q Store refrigerated food Q-Potable water <br /> 0 Store dry food/supplies 016vernight parking Er-Vehicle wash <br /> I, A4r-;Ll u f�/✓t , 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 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 %�YOa('!�— Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in S-rAyv5 kc(,5 W a-L&T&�County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The6ihbove checked services are available at the <br /> above commissary. Please notify <br /> �EHD <br /> f iif the status of their operating permit changes. (� <br /> REHS Signature �lt�� /�1 Date 9--I '2152,1 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />