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()1 <br /> <br />SA\ JOAQUIN <br />Environmental Health Department <br /> <br />COUNTY- - <br />-RECEIVED <br />OCT 1 3 2023 <br />SANTA CLARA COUNTY Mobile Food Facility Caterer LDEPTOFEUVIRONMENTAL HEALTH <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 <br /> MOtA0 <br />Lic. Plate # <br />COMMISSARY AGREEMENT <br />Owner/Operator Name S\-\%\itNiv.t..t\-- ZfksvJei <br />Business Mailing Address 15 QA ('4oycetre10..41 <br />CitySCUN ,ri-oe State CAZip q 6ti 0 Bus. Ph. Itosck %"3- et CC, ?Alt. Ph. liog cto,‘ <br />1, StA 0e14 Ror , 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 <br /> <br />Date kOlOG OA!) n-3 <br /> <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name -fc-ve mom° v_Lt- FA# <br />Address Sic\ tA0v‘ke-`r12-y facA Bus. Phone liog0t9i n."11-("4- <br />Ctc If° Owner/Operator <br />Check all appropriate services provided: <br />LW-compartment sink <br /> VElectrical hook-ups <br />.4:ood preparation and handwashing <br />c'Store refrigerated food <br /> <br />(Potable water <br />V<Svernight parking •VVehicle wash <br /> , 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 notify the EHD i mediately. <br />Signature <br /> <br />Date 10 \ 0 C <br /> <br />To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in Santa Clara 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 />:Wastewater disposal <br />LY'oIid waste disposal <br />Vot & Cold water for cleaning <br />r/Store dry food/supplies <br />REHS Signature <br /> <br />frIa4tA Lee-frir <br /> <br />Date 10/30/2023 <br /> <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd