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{ <br /> Q � v522 ) <br /> SAN JOA U I N N pp d!j?,fEnvironmental Health Department <br /> cP COUNTY Yn�-Jul <br /> I RECEIVED <br /> .gL,Foa�' Greatness rows here. RE <br /> COMMISSARY AGREEMENT OR 0 5 2024 <br /> Mobile Food Facility ♦ Caterer ENVIRONMENTAL HEALTH <br /> PERM IT/SERV ICES <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��J*sd; 4Z PLO tic. Plate# 5,e_% 2_9 9,4c) <br /> Owner/Operator Name Tatr"e ` DCO! <br /> Business Mailing Address 14M 3 We-s+La-z4, R_-'aA <br /> City jr <br /> X.M State_CA_Zip 9530 Bus. Ph.201-9144-8295 Alt. Ph. <br /> hereby state that the above information is current, true and correct to <br /> the best of m knowledge nd 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 LdC2 Date <br /> 2. To be com le ed by COMMISSARY OWNER/OPERATOR >>�� <br /> Commissary Name FA#�Qq 5`Z) )O1' <br /> Address ao- Bus. Phone r-JOCJc i 4 7 <br /> City�N ,C)Au)'-::' Zip )S--�)s_-L_Owner/Operator20LR _ L�GTU_,�' <br /> Check all appropriate services provided: <br /> Wastewater disposal 11A 3-compartment sink Electrical hook-ups <br /> Solid waste disposal Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning [�L Store refrigerated food P Potable water <br /> Store dry food/supplies Cf Overnight parking F 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 ownqf shall notX the EHD immediately. <br /> Signature Date 0H—o tl <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 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />