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+ <br />f -Nr1 7 <br />1-11 <br />\ diSteir <br />rc013.7 <br />SANAAQUIN <br />—COUNTY— <br />Greatnes s grows here <br />RECEIVED <br />JAN 31 2024 <br />STAN ISLAUS COUNTY <br />DEPT OF ENVIRONMENTAL RESOURCES <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3 <br /> <br />1. To be corn leted b APPLICANT 1 <br />Business Name '6,,,v01,2._ Lic. Plate # qi aq <br />Owner/Operator Name IN `c), ‹,\'\(\V <br />Business Mailing Address E.A\VICA <br />City EAV State (Zip ciS"-- Bus. P10-10)q3d-q-70?Alt. Ph <br />V,,\I\e'V , 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 di continued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and -Ities, <br />Signature Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name if/fetx,;* gikilept /2 FA# <br />Address /211 S. t 1'Sl- <br />Cityy Aorit5k-19 Zip q 55( Owner/Operator CA,/,'///4 gerkoc-,);4E <br />Check all appropriate services provided: <br />Erfnastewater disposal EYn-compartment sink <br /> <br />Electrical hook-ups <br />Graolid waste disposal GrFood preparation k <br /> <br />ra/foilet and handwashing <br />Gr-Hot & Cold water for cleaning 0 Store refrigerated food <br />GPotable water <br />0 Store dry food/supplies 0 Overnight parking <br />iVehicle wash <br />Ark z,is ceVE <br />Signature <br /> <br />Date <br /> <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in (3-Y\ taGLJ 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. Piease notify EHD if the status of their operating permit changes. <br />RENS Signatu <br /> <br />uff <br /> <br />JeAc1 c-' <br /> Date <br />1:31WAR j7 t ILII 3 <br /> <br />1868 E. Hazeiton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <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 immediately. <br />Bus. Phone (20'1)33g-3663 <br />\a93a9 <br />-pR 091Sg2