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SAN 10 A Q U I N Environmental Health Department <br /> - <br /> - COUNTY - -- <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 <,)M AC 1< 2W MTE S Lic. Plate# '&s <br /> Owner/Operator Name 6109REET S I I)Gik' <br /> Business Mailing Address16240 EAS\1 S-TREE <br /> City( A.%ROP State CR Zip 95330 Bus. Ph.(ZCq)(p(do- CE;3 Alt. Ph. <br /> I, 6)6-9 WE T sa N(M)A , 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(- S I'Y\440 <br /> Date QS1(012023 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name P i C&I -V q D FA# <br /> Address 391 a E m �' n/ER �Av C Bus. Phone ci- cvAV L4 cl <br /> City STOCK TCS W Zip QS 705 Owner/Operator <br /> Check all appropriate services provided: <br /> p Wastewater disposal ❑ 3-compartment sink P-5-lectrical hook-ups �; 7 <br /> Irn � <br /> p Solid waste disposal ❑ Food preparation MToilet and handwashing C <br /> ❑ Hot & Cold water for cleaning Ej1Store refrigerated food ❑ Potable water <br /> ❑ Store dry food/supplies 01bvernight parking ❑ Vehicle wash �� �_ rr <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 /> > <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the �� M D <br /> commissary owner shall notify the EHD immediately. <br /> Signature ��//� ,� �,.,�,', Date - U- 3 <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 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />