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,,p PaVlN C, <br /> 1 : SANJOAQUIN Environmental Health Department <br /> . =COUNTY— <br /> Greatness 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 /> I.t To be'com leted by APPLICANT <br /> ... ..1.�. .ci."•_ .. . ill... ._. d .5 4,.. . _.: <br /> Business Name �dia#7 5>Me.-1- Fda Lic.Plate# 4UC-2150 <br /> Owner/Operator Name Ad'I�inde.c- Si nqH <br /> v <br /> Business Mailing Address !Oq I C7ardeNia <br /> Citya State- Zip 5Q 33:4' Bus. Ph. 4Y09-3o3-$860 Alt. Ph. <br /> I hereby state that the above information is current,true and correct to <br /> the bes of my k ow edge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements, If the use of the <br /> commissary is discontinued,the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date o { ( Z Z <br /> 2. To be leted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name La, 66misart4 Aidw-5-10 FA# <br /> Address 12- 1,11 S- 7:�' 64.ee.1- Bus. Phone 1133$ -3663 <br /> City /Moo( M Zip 9535( Owner/Operator J pOjd $.t3rws,e <br /> Check all appropriate services provided: <br /> Wastewater disposal LZ(3-compartment sink RfElectrical hook-ups <br /> Solid waste disposal EY"Food preparation p1 Toilet and handwashing <br /> LJ Hot& Cold water for cleaning Cl/Store refrigerated food p Potable water <br /> Wstore dry food/supplies E1(Overnight parking vehicle wash <br /> I, M tx(k Ir-i r5 Cot 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 own' r hall n the EHD immediately. <br /> Signature i�`2 � � Date D�113/22 <br /> 3. To be completed by thSE � `_ �L�HjDri8.!L01 r06— (d e'ofFSan':Joaguin 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, n n e <br /> REHS Signature <br /> – {2�G- Date 7 (3 !Nw <br /> 1868 E. Hazelton Avenue I Stockton, California 96205 1 T 209 468-34201 F 209464-0138 www.sjgov.org/ehd <br />