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'V 3-compartment sink <br />ri4 Food preparation <br />Store refrigerated food <br />0 Overnight parking <br />i0 Electrical hook-ups <br />la Toilet and handwashing <br />g Potable water <br />0 Vehicle wash <br />, hereby state that the information I have provided is current, true and <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />—COUNTY <br />Greatness grovir <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 Name Lic. Plate # <br /> <br />Owner/Operator Name <br /> <br />cyvmsbiv ----\-\sye <br /> <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 Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br />commis is discon ued, the "it holder must notify the EHD. Failure to notify this office may result in permit <br />revo ;tion and pna i s. <br />Sig atu <br />2. To e completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name 0 c cDmt.cotAcc-c 6kTC.i-4Et4 FA# <br />Address I lC) 14- DoR400 ST. Bus. Phone (2oG08-5455- <br />City STOCK:1014 Zip cIS-2 0 2- Owner/Operator Laorxi,1 Cc:1 ErWA. GO --6-0-)14 <br />Check all appropriate services provided: <br />M Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br />Store dry food/supplies <br />I, L-SC:*te,t- C AS-T 0 <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to compl with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owne al notify the Ejmmediately. <br />Signature <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 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />Business Mailing Address q(0-7-.) Lcj- <br />City Ltolo State0\-- Zip Tc516 Bus. PI.2-eCO -q--3-00 Alt. <br />\ gam. <br />I ,S S1-2? <br />Date <br />Date 03 / I3 /23