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SAN JOAQUIN <br /> <br />Environmental Health Department <br />RECEIVED <br />JAN 31 2024 COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />STANISLAUS COUNTY <br />DEPT OF ENVIRONMENTAL RESOURCES <br />Complete sections 1 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 iLO 01- bS' vt--( Lic. Plate # <br />c2--= <br /> <br />P( AcS Owner/Operator Name <br />Business Mailing Address iN\--C 3 <br />City ry, 'bfb-11%tate Zip -5-20,13 Bus. Ph. 2C1-1(625- 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 disco d, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and p ie <br />/‘ <br />2. To be COmpleted by COMMISSARY OWNER/OPERATOR <br />Commissary Name itfax, Ocien /LC <br />Address I'LA‘ S. 14'" $A" <br />City /40,4e_5kv Zip /5351 Owner/Operator 1.0114,41 gei-k o <br />Check all appropriate services provided: <br /> <br />,L741-Nastewater disposal -a/---compartment sink <br /> <br />'Solid waste disposal <br />F-01-ood preparation.A <br />7 Overnight parking Tie'Vehicle wash <br />I, ark v s eve- , 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 />Signature Date /-3/-- 69 I/ <br />FA# <br />Bus. Phone (200338-3663 <br />La_Hot & Cold water for cleaning rni Store refrigerated food I <br />Cl Store dry food/supplies <br />e'Electrical hook-ups <br />re-i-oilet and handwashing <br />LTV15-otable water <br />Date <br />The commissary is located in (Juni 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 />RENS Signatur77 _AA Jc' 9j Date /73 e 20 7 V J . k.614-6-4-q013 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />PRO 531V(VD