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SAN JOAQUIN <br />---COUNTY <br />Greatness grows herp. <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility a Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />To be completed by APPLICANT <br />coo°. c co ((\u \-) Lic. Plate # <br />Owner/Operator Name J e VY1 A In c) <br />Business Mailing Address 2..3 “ 3 Ch e{ c) e, a ci <br />City C-A-OCk r Stateeli Zip qS2OS Bus. Ph.(Zoci j 2 ci 2 5 3/Alt. Ph. (2)c ) 3 (0 13 S--& <br />j--ecoS u-cl (Any [u , hereby state that the above information is current, true and correct to <br />the best of my knoWiedge 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 p-e mit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penAiqs. <br />Signature <br />To be poInpIeted by COMMISSARY OWNER/OPERATOR <br />Commissary Name _CA Co rY\ 'C L\ Cc FA# <br />Address .2-C1 00 c„ V\-tA (u ) W(A-\I Bus. Phonec 20'0 qlp q — LIS 20 <br />City Sim at \-0Y) 8.,6 Zip 15 ZCC Owner/Operator G . . . c " A <br />Check all appropriate services provided: <br />C Wastewater disposal <br /> El 3-compartment sink <br /> Electrical hook-ups <br />Solid waste disposal <br /> O Food preparation Toilet and handwashing <br />a Hot & Cold water for cleaning O Store refrigerated food <br /> la Potable water <br />0 Store dry food/supplies LI Overnight parking 14 Vehicle wash <br />1, INT\ (A 12.Utrark-Q.c , 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 />Signature <br /> <br />Date <br /> <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 />REHS Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />?RO 2z-1 <br />Business Name ic (y-to 4-1(, <br />Date (2_ —I 202_3 <br />