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SAN JOAQUIN <br />COUNTY <br />Environmental Health Department <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 />Business Name Fagundes Street BBQ LLC Lic. Plate #4SN5340 <br />Owner/Operator Name John Wall <br />Business Mailing Address 142 Jason St <br />City Manteca State CA Zip 95336 Bus. Ph. 844-987Z-2778 Alt. Ph. <br />1, John Wall , 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 disW <br />it holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and pe <br />Signature Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Fagundes Meats and Catering FA# <br />Address 142 Jason St Bus. Phone <br />City Manteca Zip 95336 Owner/operator Frank Teixeira <br />Check all appropriate services provided: <br />Wastewater disposal V 3 -compartment sink <br />Solid waste disposal 'Food preparation <br />%Hot & Cold water for cleaning <br />Store dry food/supplies <br />correct to the best of <br />operator fails tion <br />Ii Store refrigerated food <br />0 Overnight parking <br />VElectrical hook-ups <br />V Toilet and handwashing <br />Id <br />Potable water <br />V Vehicle wash <br />, hereby state that the information I have provided is current, true and <br />knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />with the co99��.(tions of this agreement, or if this agreement is modified or cancelled, the <br />notiXthe i D immediately, <br />1 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. I <br />The commissary is located in San Joaquin 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 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 484-0138 1 www.sjgov.org/ehd <br />