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SAN JOAQUIN Environmental Health Department <br /> COU NTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections 1 and Z If your commissary is located outside of San Joaquin County also complete section a <br /> 1. To be completed by APPLICANT <br /> Business Name Fagundes Street BBQ LLC Lic. Plate# CI-9-26)'? L 2— <br /> Owner/Operator <br /> Owner/Operator Name John Wall <br /> Business Mailing Address 142 Jason St <br /> City Manteca State CA Zip 95336 Bus. Ph.(209) 370-2272 Alt. Ph.(209)275-0561 <br /> 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 disco' <br /> e r must notify the EHD. Failure to notify this office may result in permit <br /> revocation and pen-{ ' <br /> Signature Date Z 2 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Fagundes Meats and Catering FA# <br /> Address 142 Jason St Bus. Phone(209) 239-4184 <br /> City Manteca Zip 95336 Owner/Operator Frank Teixeira <br /> Check all appropriate services provided: <br /> ® Wastewater disposal 00 3-compartment sink ® Electrical hook-ups <br /> 0 Solid waste disposal IM Food preparation 0 Toilet and handwashing <br /> 10 Hot& Cold water for cleaning 12 Store refrigerated food III Potable water <br /> 19 Store dry food/supplies 10 Overnight parking ® Vehicle wash <br /> Frank Teixeira 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 tocpm py with he coitions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary o er sh II not the EF D'mmediajely. ./ <br /> Signature Date <br /> 3. To be completed by 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 />