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k-L" <br /> SANJOAQUIN <br /> ..,.-, Environmental Health Department <br /> COUNTY <br /> Greatness grows here. \ / 0 I <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility * Caterer <br /> Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. I <br /> 1. To be <br /> completed by APPLICANT <br /> Business Name )—CA 1)00) � Lic.Plate# 1 L r.2—. <br /> Owner/Operator Nam �4L'S <br /> Business Mailing Address 1t.U� �Ghl�l Q <br /> city . %COdr\J State_CA_Zipq� b Bus. Ph.101 -SUR-q- ;-,)—Alt. Ph. <br /> I, A /a Gly 16ez'c 5 ,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 discontinued,the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signatur <br /> Date >l /1-702023 <br /> 2. To be completed by, COMMISSARY OWNER/OPERATOR <br /> Commissary Name IJY)l UY) C Mt YI V'h IYUCK 001 � FA# <br /> Addres �j S-f Bus. Phone 0c1— <br /> City�S-d CK 16 I^U Zip 5 Owner/Operatoran,4L.. <br /> Check all appropriate services provided: WASH 0-14) <br /> lb Wastewater disposal ® 3- partment sink ® Electrical hook-ups <br /> M Solid waste disposal ® Food preparation 1W Toilet and handwashing <br /> Iff Hot & Cold water for cleaning ® Store refrigerated food M Potable water <br /> ® Store dry food/su plies ® Overnight parking 0 Vehicle wash <br /> j/ hereby state that the information I have provided is current, true and <br /> correck 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 s II noti a EHD immediately. I / —7 <br /> Signature Date ! ( � / l 2 a2-3 <br /> 3�_ <br /> F37.--T7!0 be com' leted by the ENV HEALTH.'udsdidion'.outside,_`of San Jo'a 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 />