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SAN OAQUIN Environmental Health Department <br /> Yf- <br /> --COUNTY RECEIVED <br /> °171;ow'�'' Greatness grows here. <br /> COMMISSARY AGREEMENT JAN 2 3 2024 <br /> Mobile Food Facility s Caterer ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br /> Complete sections 9 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 ,-.;;-/ - _ > -yl ic. Plate# , <br /> Owner/Operator Name <br /> Business Mailing Address37 <br /> City 5U rh,-Y6FA,) StateAZip9�us. Ph,2Q y c29A-6 j 76Klt. Ph-20-.251L <br /> I,Z)L5C_ 9 ArI 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 disco ti d rmit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and pena <br /> Signature Date b '3 d '7 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name(J/11i6rX) Cf+'TL:X1 &j MGQ ( CAYeIeA# <br /> Address Z 71 7 5• 006A)6A) Sil Bus. Phone og-2-cl A - 5 <br /> ck f* 62-s/� <br /> Citys�'tf j� Zip v� Q Owner/Operator IC(a)l R&A'� / I KW <br /> Check all appropriate services provided: <br /> Wastewater disposal E3 3-compartment sink E3 Electrical hook-ups <br /> W Solid waste disposal 0 Food preparation Toilet and handwashing <br /> fit Hot & Cold water for cleaning O Store refrigerated food Potable water <br /> O Store dry food/supplies �y E3 Overnight parking ! Vehicle wash <br /> I, Vb Sr/!� ( j j a: , 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 onditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall notify EHD immediately. <br /> Signature Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />