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SAN JOAQUIN <br />COUNTY <br />-P.12 05(-1 i353 <br />Environmental Health 9.1-8tIment <br />r <br />) <br />iTANISLAUS CO. <br />DEC 1 4 2023 <br />COMMISSARY AGREEMENT <br />4t), , <br />\§" <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also comp Vatcg 3. <br />Lic. Plate # L)O j 1 c75 72 <br />0,4 /1-(E)4742s <br />319-e6 <br />City State Zip Bus. PI-00/ iing g/5-6 Alt. Ph. 4'_() 7 --e) s" 73 y <br />1, ( r /1 1.=f,c , 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 Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name \\A \‘.4-voc\c/-\ LLX FA# <br />Address \\ ---4--AA/1 S. \--ra-- Bus. Phone(2-oc' ) -3c0(40-3) <br />City \--k_0(k e.:•3-\--) Zip Cr3 51 Owner/Operator <br />Check all appropriate services provided: <br />14. 3-compartment sink <br />Food preparation <br />Store refrigerated food <br />Overnight parking <br />I, <br />Date )0.- <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in 34(ivItqati.1.6 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 />12/P-f- /23 <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 />Mobile Food Facility • Caterer <br />Business Name itr &S i 2/f 7 • 0/.71- re jw <br />Owner/Operator Name <br />Business Mailing Address <br />t Wastewater disposal <br />Solid waste disposal <br />YI Hot & Cold water for cleaning <br />tore dry food/supplies - <br />t)if Electrical hook-ups <br />Toilet and handwashing <br />d Potable water <br />171 Vehicle wash <br />, hereby state that the information I have provided is current, true and <br />co rect 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 />commi ary er shall notify the EHD immediately. <br />Sign ture <br />RENS Signature Date <br />