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PUIN <br />SAN.JOAQUIN Environmental Health Department <br />� -6 1�4-' —COUNTY— <br />c,�,v' 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 />1. To be completed by APPLICANT <br />Business Na <br />fS <br />Plate # <br />Owner/Operator Name _'fa C -JI -14-g t IK 6LPl (V -F—' <br />Business Mailing Address .547XiG/-ON 54' <br />City State Zip '1,52OBus. Ph.20J -33/,620 -Alt. Ph. 323—t?fiN 6T32- <br />1, <br />7%j2I, , 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 discontinued, the permit h Ider must notify the EHD. Failure to notify this office may result in permit <br />revocation and p nal ies. '�/ ' # <br />Sianature Date o/— 2023 <br />2. To be com leted by COMMISSARY OWNER/OPERATOR r1 <br />Check all appropriate services provided: <br />1p Wastewater disposal <br />F Solid waste disposal <br />R Hot & Cold water for cleaning <br />F, Store dry food/supplies <br />3 -compartment sink <br />51 Food preparation <br />M Store refrigerated food <br />E3 Overnight parking <br />O Electrical hook-ups <br />0 Toilet and handwashing <br />M Potable water <br />0 Vehicle wash <br />I, , 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 sbaynofy the EXD immedijt*. <br />3 To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. 1 <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 <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 />