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SAN JOAQUIN <br />COUNTY -- <br />Greatness grows here. <br />7osLi\z -g,40 <br />Environmental Health Department <br />'RECEIVED <br />COMMISSARY AGREEMENT <br />Mobile Food Facility. Caterer <br />DEC 1 6 2023 <br />ENVIRONMENTAL HEALTH <br />DEPARTMENT <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 />Business Name 124c-h° C t.tk(61 0q 4-vo C 1-1 Lic. Plate # 1 '12 <br />Owner/Operator Name !<L) Y100(1-A C\n, r-vrAci AV\c,0-1 tot <br />Business Mailing Address 3 6i 5 Corn,r\c3 <br />City vvii I e 11- ck`. State e Zip SV3S Bus. Ph. - 2 Li 1 6 <br />0 <br />2- Alt. Ph. <br />I, 1-(0 kiirrt 6 , 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 Rermit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalti s. <br />Signature <br /> <br />C <br /> <br />Date 2 - 2 Lo - 23 <br /> <br />To be completed by COMMISSARY OWNER/OPERATOR <br />r o f Ck. <br />E 0,1r- )a'/ <br />City \ 0 Ch Zip ci 2-0 Owner/Operator t-t p" A r <br /> <br />C Vt•-r\ <br />Check all appropriate services provided: <br />jel Wastewater disposal <br /> <br />GO-compartment sink <br /> IS Electrical hook-ups <br />Et Solid waste disposal <br /> <br />O Food preparation <br /> El Toilet and handwashing <br />Ef Hot & Cold water for cleaning <br /> O Store refrigerated food <br /> <br />fit Potable water <br />0 Store dry food/supplies <br /> <br />MOvernight parking <br /> MVehicle wash <br />I, AiA rc-s- VtCt ,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 n9lfy the EHD immediately. <br />Signature 2-- Date -2(e -77 <br />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 />Commissary Name <br />Address 2 '1 0 0 <br /> <br />Co{ p <br />Bus. Phone <br />FA# <br />