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Environmental HealthL ment <br />COMMISSARY AGREEMENT <br />Mobile Food Facility • Caterer <br />SAWOAQUIN <br />COUNTY <br />Greatness grows IlL <br />sEp 0 5 2024 <br />ENVIRONMENTAL HEALTH PERMIT/S <br />ERVICES <br />Date Signature <br />revocation and penalties. <br />rA oVo,s/p2ti <br />. - • <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 />Lic. Plate # 12/ V3 <br />Owner/Operator Name IcAltiatAle CAN bi ‘nrtaltAkyo <br />Business Mailing Address OS1D /1/461_,2_ 124 <br />City —Tyl ag-- StateCA Zip 0-tnt1 Bus. Ph. gc,2-6,214 ?--8,27-0Alt. Ph. <br />Cu)J NitykOt4h..0.44j; , 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 older must notify the EHD. Failure to notify this office may result in permit <br />Business Name /_,VC)4, ã.L7_ <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name /P`ree-.._ FA# <br />Address 6. 2G S 5L Bus. Phone <br />city 2._&p Zip ci Owner/Operator <br />Check all appropriate services provided: <br />Ile:compartment sink -Wastewater disposal <br />W‘olid waste disposal <br />miit & Cold water for cleaning <br />&Store dry food/supplies <br />6..00d preparation <br />Store refrigerated food <br />6/Overnight parking <br />alectrical hook-ups <br />oilet and handwashing <br />rill‘table water <br />rife-'chicle wash <br />071 , 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 c7 - <br /> <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 I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />PR051-4n-ltio