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SAK OAQUIN Environmental Health Department <br /> —COUNTY— <br /> cqt �' Greo±mess grows here. <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 /> 1 . To be completed by APPLICANT <br /> � �r <br /> Business Name ! 1Tti j, A-a sl_r'rt:/Oa LtC Lic. Plate# L { q b9 <br /> Owner/Operator Name wrr i,5 f ker- �IVirIG <br /> Business Mailing Address 1103/ 5• CGY'G'G�r I-e,, /2d <br /> City f4OJeSk State 61 Zip qC_,?T9 us. Ph.Z09 613 V634 Alt. Ph. <br /> I, I'�X-4rADhPr Iwo r'6, , hereby state that the above information is current,true and correct to <br /> the best of my kfiowledge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San JogQn County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is dis4odfinu , the per er must notify the EHD. Failure to notify this office may result in permit <br /> revocation and pial ' <br /> Signature Date <br /> 2. o be p6mpleted by COMMISSARY OWNEWOPERATOR <br /> CoLlXsary Name LQ Com)%rio Aooent o FA# <br /> Address 1211 5. -4' $a-vend Bus. Phone 62og)33%-3G43 <br /> City /f'lorleol-o Zip 45351 Owner/Operator (fo1WlSlwage <br /> Check all appropriate services provided: <br /> )M Wastewater disposal ;I 3-compartment sink 18 Electrical hook-ups <br /> IR Solid waste disposal 14 Food preparation ® Toilet and handwashing <br /> IR Hot & Cold water for cleaning 12 Store refrigerated food 3 Potable water <br /> ;0 Store dry food/supplies Overnight parking 93 Vehicle wash <br /> I, /Hark Lv 1 s^Glut , 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 /f(({ilfcgr� : Date 2/253/22 <br /> Ti <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin Co. <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in CdIffornia Health & Sa ety Code. The above checked services are available at the <br /> above commissary. Please not, the s tus of their operating permit changes. <br /> REHS Signatur Date <br /> 1868 E. Hazelto enue 1 Stockton, California 5 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />