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Environmental Health De ailment <br />RECEIVED <br />APR 0 5 2024 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />Complete sections 1 and a If your commissary is located outside of San Joaquin County also complete section 3. <br />1. To be completed by APPLICANT <br />• <br /> SAN ..10AQUIN <br />trk COUNTY <br />s <br /> Greatness grows here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility c Caterer <br />ba t/t/ C <br />Owner/Operator Name Br yo,4-1--bg <br />'1,/(0 Business Mailing Address lO _ 4., ri Zam,e <br />Business Name 132 Lic. Plate #4.(g12_.3_...2— <br />City 1 State 04-- Zip 993 37 Bus. Ph. 5/0 851 - 02*0 Alt. Ph. 570 Y5/--/060 <br />6 f-yolvi Da viS , hereby state that the above information is current, two 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 enalties. <br />Signature C1444,a- Date 3 <br />2. To be co pleted by COMMISSARY OWNER/OPERATOR <br />Commissary Name1 yk44,1-- FeiDOV 17b4 2.2A FA# 67027 I?3 <br />Address //L &) /4 /.4 Bus. Phone 207 -7/ Z;b 2.°463 <br />Rrovn?€ Owner/Operator <br />E-Wastewater disposal <br /> <br />O 3-compartment sink 0 Electrical hook-ups <br />ja--olid waste disposal <br /> el Food preparation :ia-Toilet and handwashing <br />Hot & Cold water for cleaning O Store refrigerated food _0—Potable water <br />Store dry food/supplies O Overnight parking 0 Vehicle wash <br />I, 1r.551$11't Rein% , hereby state that the information I have provided is current, true and <br />correct to the best of my knowledge nd 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 sh I notify the D immediately. <br />Signature Date 3/1)/1-1 _ <br />. City ‘4140,4f,,70 Zip <br />Check all appropriate services provided: <br />3. To be co pleted by the ENV :elk_TH 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 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />i712 oq 0 2,)&