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Environmental Health Department <br /> RECEIVE® ,4 ,i 1 N <br /> AISSARY AGREEMENT <br /> JAN 2 0 2023 <br /> obile Food Facility ♦ Caterer <br /> ENVIRONMENTAL HEALTH <br /> PERMITISERVICES nissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> Business Name 13:Q= 1�2'1V Lic. Plate <br /> Owner/Operator Name Gln 6 1 Yfl1c" <br /> Business Mailing Address <br /> City_t �r. Statel,AZip Ct 15.Bus. Ph(aPq 4=E ti Lo 5 Alt. Ph. <br /> , 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 Joaqui County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, ermit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalti <br /> Date <br /> Signature <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name A COfr1�Sa ria n�c<�v FA# <br /> Address 1211 ��h /8e� Bus. Phone_(jQq ��`x '3(0(03 <br /> City MO&S�o <br /> Zip q65 / _Owner/Operator QAC' <br /> Check all appropriate services provided: <br /> 12 Wastewater disposal IR 3-compartment sink IM Electrical hook-ups <br /> q Solid waste disposal 13 Food preparation IN Toilet and handwashing <br /> 13 Hot & Cold water for cleaning IA Store refrigerated food M Potable water <br /> 0 Store dry food/supplies ® Overnight parking 53 <br /> Vehicle wash <br /> ma u i 5 Cwt , 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 i �""�� �� Date 2 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in n15 jaVc 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 EHDifthe status of their operating permit 21 <br /> changes. <br /> REHS Signature Illi- �ri�lutrd , Date I t� �� <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 />