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SAN .1 <br /> <br />Environmental Health Department <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 />To be completed by APPLICANT <br />Business Name Braz Burger Lic. Plate # 4UB433 <br />Owner/Operator Name Anderson de melo <br />Business Mailing Address 2213 country oak In <br />City Stockton statCa Zip 95205Bus. Ph. 2092241997 Alt. Ph. 6502717557 <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 Sari-Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinued, the perrn!f holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. 4 <br />Signature <br />Date <br /> 02-03-23 <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Otyi,/;et,..) Conim,s..4zy FA# <br />Bus. Phone 415 54'g. 6ociq <br />City Zip 144 136) Owner/Operator ati,14-(t) Tram G.;.C&) <br />Check all appropriate services provided: <br />kr Wastewater disposal <br /> <br />O 3-compartment sink <br /> <br />Electrical hook-ups <br />Solid waste disposal <br /> <br />O Food preparation <br /> <br />ti Toilet and handwashing <br />a Hot & Cold water for cleaning <br />O Store refrigerated food <br /> <br />It Potable water <br />Store dry food/supplies fa Overnight parking <br /> <br />Di Vehicle wash <br />i44-( opIcA ) , 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 s all ify the EHD immediately. <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 />Address 6100 Atievudie- 0 <br />Date