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SAN JOAQUIN <br /> <br />Environmental FREtelaplikErent <br />APR 3 0 2024 <br />COMMISSARY AGREEMENT E NVIRONMENTAL <br />PERMIT/SERVI <br />HEALTH <br />CES <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 />To be completed by APPLICANT <br />Owner/Operator Name "c!- (d t-vh. /71( <br />Business Name gfr,-,/ e co Lic. Plate # YTS CV5 2 <br />Business Mailing Address 7C, plerilf <br />City Lod(' State ete) Zip 95257 Bus. Ph. 2oC1 6,&3-173 2 Alt. Ph. <br />I, g ca-v,tra6,4 71-c <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 discontinue the permit ho • :,„. ust notify the EHD. Failure to notify this office may result in permit <br />revocation and pena <br />Signature <br />To be cornpletectlflaraleiWY401.490EMTOR <br />Commissary Name S70 4ij2'i 2D (1-(bbie) FA# <br />Address 5.2o1 p Vine R.1) Bus. Phone ‘3 -7 832 <br />City LOW(' Zip Q291 C) Owner/Operator d c/h, <br />Check all appropriate services provided: <br />Date 6 -2' <br />1:1 Wastewater disposal <br />13 Solid waste disposal <br />0 Hot & Cold water for cleaning <br />—1:1--S..tore dry food/supplies <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 • s agreem- • - or if this agreement is modified or cancelled, the C'5,1 ke-sdk commissary owner s or the EH • - 'late' <br />-El—Overnight parking ), „ a Vehicle wash <br />, hereby state that the information I have provided is cuttirltrfthe glect <br />siarcrif <br />-Era:compartment sink -ErEITetrical hook-ups <br />thFood preparation <br />0 Toilet and handwashing <br />12-Store refrigerated food <br />-a-Potable water <br />Signature Date <br />3. o 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 1 209 468-3420 I F 209 464-0138 www.sjgov.org/ehd