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SAN JQAQUIN Environmental Health Department <br /> .: OU NTY <br /> eat. ess grows here. RECEIVED <br /> APR 151��� COMMISSARY AGREEMENT APR 0 5 2024 <br /> s�PN,s,�usco� <br /> DE410FENV1RONMENtP�RESOURCES Mobile Food Facility ♦ Caterer <br /> ENVIRONMENTAL HEALTH <br /> PERMITISERVICES <br /> Complete sections 9 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 aco5 Al Paso Lic. Plate# 112M (O-9450 <br /> Owner/Operator Name Jairrie ?&L& <br /> Business Mailing Address 14655 lNe4 La.rc�, Rl d <br /> City v State_CA Zip9530 Bus. Ph.209-914-8$,95 Alt. Ph. <br /> 1, hereby state that the above information is current, true and correct to <br /> the best of my knowle Ng e- 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 completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name FA# r,90f5g1 / 0�� <br /> Address b L11 Bus. Phone 7T <br /> City ,m od 1 Zip 3 S Owner/Operator `]fib-P- . f('Lc' <br /> Check all appropriate services provided: <br /> Wastewater disposal IR 3-compartment sink IX Electrical hook-ups <br /> Solid waste disposal ! Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning ! Store refrigerated foodP(Potable water <br /> Store dry food/supplies Overnight parking /W Vehicle wash <br /> ( 0`YA 1.�AM , 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 r shall tify the EHD immediately. <br /> Signature XDate <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in 6tay sl alis 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. PI ase notify EHD if the status of their operating permit changes. i 1 <br /> REHS Signature °V Date—'+I1512024 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />