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Environmental Healt e <br /> SANJOAQUIN _partment <br /> COU NTY---- UEIVED <br /> -ovy, it r <br /> NOV 3 0 2023 <br /> COMMISSARY AGREEMENT E'N"11?0N1%1LNTAL HEALT[I <br /> Mobile Food Facility * caterer 1)1'13ARTIVIENT <br /> Complete sections I and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> PPLICANT <br /> 41 <br /> Business Name -TO e sC' t'C' V_(A Lic. Plate# V <br /> Owner/Operator Name ISO rt be k C_y + ( -2 <br /> Business Mailing Address 7_6 C C V-1 <br /> Cit styc'kl6n State_jAlZip 'JI520; Bus. Ph. (26c, 1l;_67-332Alt. Ph. <br /> 1, W(A X , \o ff 1-YA G Y- �I V_%P- Z, 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 RWVXL"'i K. Date 2-6 <br /> LZWilffi-1,10 iit'.d 0;j <br /> TM N COMMISSARY OWNER/OPERATOR <br /> Commissary Name X,5� L_ FA# <br /> - , IV — <br /> Address_,_,���a I-Bus. Phone L/,)`j- <br /> 7 F <br /> City -�&&-- Zip 0vvnPrAperator,A tc. 6_111W <br /> Check all appropriate services provided: f <br /> 1A Wastewater disposal It 3-compartment sink MElectrical hook-ups <br /> 116 Solid waste disposal M Food preparation E3 Toilet and handwashing <br /> a Hot & Cold water for cleaning 13 Store refrigerated food 13 Potable water <br /> E3 Store dry food/supplies U Overnight parking MVehicle wash <br /> 1, li\V\C_ "\;G,r C,;- ir-v L 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 shall noti he EHD immediately. <br /> Signature l Date 2- 6 2- 3 <br /> NV HEALTH jurisdiction outside of San Joiduk04 <br /> _ '- <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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />