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/J?k 0 s3 7 / 0 2 <br /> SAN WOURRECEIVEDironmental Health Department <br /> ---COUNTY--- <br /> ' Gre.otness qrows he-P. OCT 0 3 2023 <br /> VIRONMENTAL HEALTH <br /> C01JW"IMYAGREEMENT <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 /> 0 <br /> Business Name%''O, r��S� �}u'�> Lic. Plate# 84111, \9 <br /> Owner/Operator Name' $r ak� i\ <br /> Business Mailing Address <br /> City 5 7c7�.,(._ L,,_ State4A\_ Zip A 1.iU Bus. Ph:^L_j0j —%j 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 Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature I r== Date lo - 3-2-1 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 4 !V G FA# Nk <br /> Address 1211 J- V" _51L Bus. Phone (;2og)338-_3663 <br /> City AodesA, Zip q!5 3 5 i Owner/Operator <br /> Check all appropriate services provided:. ��J� ��c ' �C ,sSa, � <br /> c d� J <br /> g;rWastewater disposal [ 3-compartment sink LK Electrical hook-ups <br /> esow waste disposal E3 Food preparation PJ'-Toilet and handwashing <br /> Hot & Cold water Mr cleaning 0 Store refrigerated food [(Potable water <br /> E3 Store dry food/supplies WOvernight parking L3 Vehicle wash <br /> I, Xr L L.;5 C,r>i-f- , 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 sh II notify the EHD immediately. <br /> Signature Date 10--3.23 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin Co. <br /> The commissary is located in �Cli.��OUl , C_(LkM-iA County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. qe above checked services are available at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> 1 11 <br /> REHS Signature )Zvm-- Date 1�� 11' b _ <br /> VerOndj <br /> 1868 E. Hazelton Avenue I Stockton, Calffomia 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br /> S <br />