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SAN JOAQUINa <br /> Environmental Health Department <br /> --_' <br /> COUNTY- <br /> - <br /> ouNTY RECEIVED <br /> RECE*rVEDc�ar�tness grows here. <br /> APR 15101b COMMISSARY AGREEMENT APR 0 5 2024 <br /> S7 is us DEPT OF ENVIRONMENOP RESOURCES ENVIRONMENTAL HEALTH <br /> Mobile Food Facility ♦ Caterer PERMIT/SERVICES <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 7� os 4Z fpaso Lic. Plate# 542-994+c) <br /> Owner/Operator Name T2irne `P?�6 <br /> Business Mailing Address 11883 Wes{'Larck P- as <br /> City -rra -State CAZip 9a3U`F Bus. Ph.2-Cn-9�q-g295 Alt. Ph. <br /> I,� %/'7 - � 5/'t" hereby state that the above information is current, true and correct to <br /> the be'st-'of m 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 /> Signature Date <br /> 2. To be Com le ed by COMMISSARY OWNER/OPERATOR l <br /> Commissary Name FA#,g0g5 `>�Z/ )U?y <br /> Address o� Bus. Phone�.j()Cinr�Z] ) ) 7T_�LS <br /> city ONQd k� ) Zip Owner/Operators <br /> Check all appropriate services provided: <br /> Wastewater disposal Ig 3-compartment sink Electrical hook-ups <br /> Solid waste disposal Food preparation M Toilet and handwashing <br /> Hot & Cold water for cleaning [�L Store refrigerated food Potable water <br /> itt Store dry food/supplies Cf Overnight parking `P 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 own shall noti the EHD immediately. <br /> Signature Date 0 ()5���� <br /> 3. To be completed b thhe1 ENV HEALTH jurisdiction outside of San Joaquin <br /> LSCCo. <br /> The commissary is located in o V)�51 a-us 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. P f ease notify EHD if he status of their operating permit changes. <br /> REHS Signature Date 15 1202-4 <br /> 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> '�12 0 S 22131 <br />