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S A N O A Q U I N Environmental Health Department <br /> RECE --COUNTY-- RECEIVED <br /> IVJW. s grows here. <br /> NOV ? 0 7n^., <br /> NOV 2 0 2023 COMMISSARY AGREEMENT. ,N „ZONN,,..N ,AL III,ALrI, <br /> L'NVIRONNIEN IAL 1-1EAL"I'II Mobile Food Facility t, Caterer 1)FRA RTNIEN'F <br /> Uh:PAIt7'�IENT <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 (_ L Lic. Plate# <br /> Owner/Operator Name �,� fa IL'!7i�t_A- { 1 Chu yai — LC= PL <br /> Business Mailing Address 3 -� l(: U/�(„5 �►� <br /> CityState Cr) Zip �us. Ph. 605 6i6 7 LIt. Ph. <br /> I, ��t✓l/)- I (a L2A-1.L,/-Vhereby 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 r i`LCA �'� ��r C c-k, Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name J N A .L; C 1'�7(:PC I/V r I k=-�U't C L rA- /(- <br /> Address 1 -7 L N i 6 ,U - Bus. Phone <br /> City �����<�� Iti Zip C) .�C L Owner/Operator � �;� �� �(/�,1�►JV <br /> Check all appropriate services provided: <br /> ® Wastewater disposal 49 3-compartment sink 13 Electrical hook-ups <br /> * Solid waste disposal Food preparation G Toilet and handwashing <br /> ® Hot& Cold water for cleaning a Store refrigerated food 13 Potable water <br /> 0 Store dry food/supplies ff Overnight parking D Vehicle wash <br /> r. <br /> I, LI iILL, hereby state that the information I have provided is current,true and <br /> correct 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 ownQr shall notify the immediately. <br /> Signature Date 1 1 1 .2 (:) ' 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 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />