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SAN JOAQUIN <br />COUNTY <br />Environmental Health Department <br />RECEIVED <br />i COMMISSARY AGREEMEN11 JAN 3 1 2024 <br /> <br />S IANISLAUS COUNTY <br />Mobile Food Facility Caterer i DEP1 OF ENVIRONMENTAL RESOURCES I <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1. To To be completed by APPLICANT <br />Lic. Plate # n Li <br />Owner/Operator Name <br />Business Name <br />9/c2 <br />Business Mailing Address 'Z <br />City TY 0-I%tate 0 Zip 3 Bus. Ph. 'C'IriCD-243Cr Alt. Ph. <br />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 discopf d, the permit holder must notify the END. Failure to notify this office may result in permit <br />revocation and pe le <br />1, <br />Signature Date /-3/- <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />J <br />Commissary Name 110.y, <br />Address ‘7..\\S . 1SA- <br />City A0,4 e_5 k-D Zip /53 54 <br />FA# <br />Bus. Phone (200338 -3663 <br />Owner/Operator (A )Ilia ,, gerk <br />Oden 2( <br />Check all appropriate services provided: <br /> <br />Lr Wastewater disposal ii'l--compartnnent sink <br /> <br />"Solid waste disposal L—ii'Food preparation <br /> <br />Hot & Cold water for cleaning Store refrigerated food <br />4 r Store dry food/supplies 0 Overnight parking I) <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 own r hall notify the EHD immediately. <br />Signature <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in :)•i-t \,1/"It i kf; i bi. l)L.:3 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 /> Date //!i 7('' 7 t- <br />, <br />, i ,ervf-i-S-,i3 ' <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />-"--Electrical hook-ups <br />Toilet and handwashing <br />.15-otable water <br />Vehicle wash <br />a <br />Date 01/4 yZ Y <br />RENS Signatur <br />PRo931-teu2AD