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SAN JOAQUIN Environmental Health Department <br /> a ' —COUNTY— <br /> p /'+ -gPtr Greorness grcr.,s her= <br /> JAN 10 2024 COMMISSARY AGREEMENT _ <br /> CCEH Mobile Food Facility♦ Caterer <br /> Complete sections 1 and 2. Ifyour commissary is located outside of San Joaquin County also complete section 3. <br /> 7.To be completed by APPLICANT _ <br /> Business Name ;•3'l !r:,�:a �_ %!2['c'�'' 1ic.Plate# 1 i W q le,- <br /> Ovmer/Operator Name_._) <br /> Business Mailing Address r L," <br /> City-C r t lam! ;v State1_-r Zip_Ls t41."r, Bus.Ph. ��' <,:i; Z Vx1t.Ph. _---_ <br /> j r i l7 ) )_.'4 '� hereby state that the above information is current,true and correct to <br /> the best of my knowledge and agree to ufili7e my approved commissary in accordance with Califomia 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 /> Signature79 -- — ------ —Date f b: �z G t�� <br /> 2. To be completed by COMMISSARY OWNERIOPERATOR --j <br /> Commissary Name `t Cr t it i t` ; t; FA#_� <br /> Address Bus.Phone <br /> City ' Zip c,' OwnerlOperator_ <br /> Check all appropriate services provided: <br /> a Wastewater disposal _.Yd-comparime nt sink -E3-Electrical hook-ups <br /> - Solid waste disposal O'Food preparation 13 Toilet and handwashing <br /> Q"Hot&Cold water for cleaning i7Store refrigerated food 43"Potable water <br /> -®•Store dry food/supplies 6 Overnight parking O'Vehicle wash <br /> C <br /> I, - ��•)l� 1.1---1----- -.._ hereby state that the information I have provided is current,true and <br /> - -- ...-- <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 immediately. J <br /> Signature --`.rY;_ f r.��1<<..I.c"1. — -----Date <br /> (3 To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co <br /> The commissary is located in rom'(-CA (mtol 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 /> REHS Signature ____—_Date___.-_ <br /> 1868 E.Hazelton Avenue I tockton,California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov org/ehd <br />