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SAN J O A Q U I N Environmental Health Department <br /> IJNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <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 H e0 va f) J G e Lic. Plate# <br /> Owner/Operator Name D 6)r)/,4—t L4 N <br /> Business Mailing Address I ?_5 1 <br /> City I� 01f 0tateZip����Q3us Ph. Alt. Ph. <br /> I, / C/I ) W y 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. � C72_ Z 0 N <br /> Signature�� Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Stockton Community Kitchen FA# <br /> Address 110 N EL Dorado Street Bus. Phone (209)608-5455 <br /> City Stockton Zip CA Owner/Operator RIMA BARKETT <br /> Check all appropriate services provided: <br /> X Wastewater disposal 0 3-compartment sink ❑ Electrical hook-ups <br /> X Solid waste disposal ® Food preparation Toilet and handwashing <br /> X Hot & Cold water for cleaning ® Store refrigerated food Potable water <br /> X Store dry food/supplies ❑ Overnight parking D Vehicle wash <br /> I, , 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 ow notify the EHD immediately. <br /> Signature Date 04/03/2024 <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 />