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RR 09-1 -1-12 <br />Environmental Health Department <br />Greatness grows here. <br /> RECEIVED <br />COMMISSARY AGREEMENT DEC 2 8 2023 <br />Mobile Food Facility. Caterer ENVIRONMENTAL IIEALTII <br />DEM R"I'M ENT <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />To be completed by APPLICANT <br />Business Name , r- 1,4 c.7 Lic. Plate # <br />Owner/Operator Name fk, (2,\ 127/ CA <br />Business Mailing Address 3 5 5/-1 TO 0 t-1 (-5 - <br />City (t 0 3,e5 4-0 statezipW5A3us. PI() 0 cf) 5 q L -1 (516Pt <br />, 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 END. Failure to notify this office may result in permit <br />revocation and penalties. <br />Signaturej— r e-e cA <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Jti (Y\o-!LtS FA# CiV el 5q /099 <br />Bus. Phone otoq 4-1 <br />City 'ACCIOL Zip 9 Owner/OperatorQ, <br />Check all appropriate services provided: <br />p-3-compartment sink <br /> Fr Electrical hook-ups <br />IA Food preparation <br /> ra-Toilet and handwashing <br />a Store refrigerated food <br /> ckPotable water <br />J Overnight parking <br /> er Vehicle wash <br />i(NCif (-Seft , 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 hall notify th HD immediately. <br />/02 418 k3 Date <br />To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in 51-A)1b‘...AU.5 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 />V247Aly5 <br />sAN joAouiN <br />0, COUNTY — <br />iq.24 e{ 0 c-k <br />F; 1 /4./ e roc4 <br /> <br />Date! J3 <br /> <br />Commissary Name <br />Address (-)Ot pf) (yr° <br />pkWastewater disposal <br />Solid waste disposal <br />p Hot & Cold water for cleaning <br />ra Store deg food/supplies <br />Signature <br />CC.% ‘21 agItY0,01-4) <br />REHS Signature <br />1868 E. Hazelton Avenue I Stockton, California 95205 I 1 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />Date