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SAN JOAQUIN 'wart Environmental Heal <br />RE <br />eE <br />APR 30 2024 <br />COMMISSARY AGREEMENT 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 />To be completed by APPLICANT <br />Business Name RA(A) CPC:-Cee comee,4 y Lic. Plate # 5 /T5 6 'I 5 3 <br />Owner/Operator Name 116-Ctie--rd <br />Business Mailing Address 2(0; kr).4 I/Ard c. <br />City 00//10 5 PA 77,3 State CA Zip1915 22 Bus. Ph. 20 q-f. Alt. Ph. <br />I, 2,-&40.-i EA4C-Ie <br />Date <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name LOMMC-,S01(..:S kr.S1/4--er0 FA# <br />Address (oKS.QO Bus. Phon4 2cc7) 2-3 <br />City Zip c1 Owner/Operator Owner/Operator k'SP60 \Nrk , No, (-,ca (a <br />Check all appropriate services provided: <br />Uj. Wastewater disposal <br />iZLSolid waste disposal <br />;5-Hot & Cold water for cleaning <br />0 Store dry food/supplies <br />J7/ , 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 <br /> <br />Date <br /> <br />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 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />9-11-7-1-‘12. <br />, 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 not the EHD. Failure to notify this office may result in permit <br />revocation and penalti <br />Signature <br /> <br />% <br />3-compartment sink <br />Food preparation <br />Store refrigerated food <br />Overnight parking <br />o Electrical hook-ups <br />It Toilet and handwashing <br />cL Potable water <br />p-Vehicle wash