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SAN JOAQUIN Environmental Health Department <br />• I <br />COMMISSARY AGREEMENT <br />Mobile Food Facility • Caterer <br />Crimp/Cr, No rriviN I anti 2 if kk7nletl outsxle ol San Joaquin Cannily also complete SeChfIrl 3 <br />IT To be completed by APPLICANT <br />BUstriess Name 614 ..Pf°19172- GC. el$ bc Plate <br />OwnerCiperator Name MK, 11114Ln-t4t <br />Business Mailing Address lq El 9 • CeAST <br />City 04U 1301UfState cIA Zip q 24 SLBus Ph OP . 555.* VCCS Alt Ph hi. ,4'„ .95Se <br />I Atilt- 17114 !Aril 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 Joaouin County Environmental Health Depanrrent (END) requirements If the use of the <br />commAsary is d•scontinued the perrnd holder must notify the EFID Falure to notify this office may result in permit <br />revocation e.na penalties <br />Signature t Dale /0ft-i2 5 • <br />L2. To be completed by COfIMISSARY OWNER/OPERATOR <br />Commissary Name Stockton Community Kitchen FAa <br />Address 110 N El Dorado Bus Phone (209)608-5455 <br />City Stockton <br /> <br />Zip 95202 Owner/Operator Rime Barkett <br /> <br />Check all appropriate services provided <br />Wastewater disposal <br />a Solid waste disposal <br />CI Hot & Cold water for cleaning <br />el Store dry food/supplies <br />Ci 3-compartment sink <br />19 Food preparation <br />13 Store refrigerated food <br />0 Overnight parking <br />CD Electrical hook-ups <br />13 Toilet and handwashing <br />Potable water <br />Vehicle wash <br />I Rata Barket1 <br />con red to the bes' <br />operator fails to <br />cornmssaiy ati.rt <br /> hereby state that tne information I have provided is curl er.t true and <br />-,,04,-foe and meets the California Health & Safety Code requirements If the food facility <br />. • - nd.tions of th;s agreement or if this agreement is modified or cancelled. the <br />"'"edistety <br /> <br />Date / 10/112023 <br /> <br />S grange__ <br /> <br />13 To be coleted by the ENV HEALTH jurisdiction outside of San Joaquin Co. . _mp _ <br />The cc-nmissaiy is located in County The above food facility meets the <br />iez ,ernerts in Caiifornia Health & Safety Code The above checked sennces are available at the <br />c,,-.1.ssary Please notify END if the status of their operating permit changes <br />ci HS E,,r•a'..re Date <br />I Stockton Callxna 95205 I 1 209 468-3420 I r 209 464-0138 I WVAV sigov org'ehd