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SAN.� JOAQUIN <br /> Environmental Health Department <br /> COUNTY R5C/R <br /> " " ©Greatness or ,+v; l:er <br /> NOV 11 2023 <br /> COMMISSARY AGREEMENT "NVIRONMEN7-AL <br /> Mobile Food Facility o Caterer PERMIT/SERVICSLTH <br /> Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 'I. To be completed by APPLICANT <br /> Business Name ),CA t OVI ktA Lic. Plate# '-I L3L'/ 37�- <br /> Owner/Operator Name kA (AA(A -10 <br /> Business Mailing Address ILOL ��tih r <br /> Ci ��K��AJ State ("A4- <br /> Zip'� ffl' Bus. Ph. 3 L- Alt. Ph. <br /> I, X46nM ® �/�,/���C.� 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 /> Date <br /> Signature <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name UYl l OV) Ae rl r`y 1 rucr (fI7e-j�- FA# <br /> Address_; 1 1-1 -S U y\) ti0_1�) 1_1 Bus. Phone u!i 2A�7" U11 b <br /> CiCK-10 A) Zip `�� - Owner/Operator ` ' ►� �J2AI�a <br /> Check all appropriate services provided: <br /> M Wastewater disposal Z1 3-compartment sink 0 Electrical hook-ups <br /> 13 Solid waste disposal J Food preparation D Toilet and handwashing <br /> 0 Hot & Cold water for cleaning U Store refrigerated food U Potable water <br /> ® Store dry food/supplies U Overnight parking 0.Vehicle wash <br /> UPy (/C;1 ')��� 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 ��,.,�� Date �S OZ <br /> 3. 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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />