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SAN JOAQUIN <br />--COUNTY - <br />Greatness grows here. <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 />1. To be completed by APPLICANT <br />vki kacii <br />Owner/Operator Name \k} 50 V`-e. <br />Business Mailing Address <br />Lic. Plate # H V12- 2-(0 <br />CAArt CJr <br />Business Name <br />City ( StateQ_O- Zip q S3-7 -) Bus. Ph. Alt. Ph. ICP Si .)--6 ci <br />I, kk5 , hereby state that the above information is current, true and correct to <br />the best of 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 an nalties <br />Signatute <br /> <br />Date t2_ 2-0 2_3 <br /> <br />2. To be completed by OMMISSARY OWNER/OPERATOR <br />Commissary Name <br />Address ,29 <br />City 3-4- <br />Check all appropriate services provided: <br />MI Wastewater disposal <br /> at 3-compartment sink <br /> <br />O Electrical hook-ups <br />ati Solid waste disposal <br /> <br />51 Food preparation <br /> O Toilet and handwashing <br />a Hot & Cold water for cleaning <br /> 0 Store refrigerated food <br /> O Potable water <br />0 Store dry food/supplies <br /> at Overnight parking <br /> O Vehicle wash <br />cA (54. r-OLVLP-) , 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 />e <br />zip qs-x3--- <br />FA# <br />Z-da-Z,Bus. Phone ,M?- - <br />Owner perator A. fi_e_//--, <br />commissary owner shall not. y the EHD immediately. <br />Signature <br /> <br />Date <br /> <br />/2 — O'Y —2-023 <br /> <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 />RENS 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 />PROSLIg2l-k