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Environmental Health Department <br /> '..Mrd•`: <br /> RECEIVED <br /> REC <br /> JAN c 0 2023 AISSARY AGREEMENT <br /> obile Food Facility ♦ Caterer <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES . nissary is located outside of San Joaquin County also complete section 3. <br /> 1 . To be completed by APPLICANT <br /> Business Namei (�v k >< Lic. Plate <br /> Owner/Operator Name HO \n � � Yrll�dG <br /> Business Mailing Address ;�S1 S <br /> City f)V:U-L�j-o J, State Zip jS�1 SBus. Ph��o�j) zZ 6to 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 /> Signature Date <br /> 2. To be completedby COMMISSARY OWNER/OPERATOR <br /> CommissaryName /Ot COM-150r-10' M 5 b FA# <br /> Address JEA 5 24h p Bus. Phone (Z oq) -3(� <br /> City AO&4AD Zip �535� Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal 01 3-compartment sink IM Electrical hook-ups <br /> Solid waste disposal 13 Food preparation IN Toilet and handwashing <br /> P Hot & Cold water for cleaning 14 Store refrigerated food M Potable water <br /> 10 Store dry food/supplies ® Overnight parking 63 Vehicle wash <br /> 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 —Date �2� <br /> 3. To be com leted by the ENV HEALTH 'urisdiction.outside of San Joa uin Co. <br /> The commissary is located in ! 44 r'%I S 112 V, 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 changes. <br /> REHS Signature K 1-�— NSG C'u . ,-I"-' Date �� Z <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 />