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S A N J 0 A QU I N Environmental Heaartment <br /> COUNTY— ft�)FjjJ <br /> ED <br /> JUN 0 6 2024 <br /> COMMISSARY AGREEMENV'"RON1111ENT <br /> AL Mobile Food Facility o Caterer oEPARTN ENT��L7H <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1:7o be com leted by APPLICANT = - <br /> Business Name�,-.-�p '' I & AlmZC1y CLja Y�ic. Plate# <br /> Owner/Operator Name /hTrzZmP a Cn a{���� <br /> Business Mailing Addresst <br /> City L j U J X 14 State_Cfa.Zip'7�2.34 Bus. Ph. 20 Z ��,3 (/Alt. Ph. <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 notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature — . �� Date r, -- — 26 2T <br /> 12.1-0- be com leted b COMMISSARY OWNER/OPERATOR - _ -- <br /> Commissary Name �pHJ( �C`( otFA# <br /> Address {r li�u I�p� j;-e Bus. Phone S' <br /> City ��41 Zip C Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal lt�3-compartment sink o(Electrical hook-ups <br /> Solid waste disposal 12 Food preparation Toilet and handwashing <br /> Hot& Cold water for cleaning ® Store refrigerated food Potable water <br /> 13 Store dry food/supplieC.s�� Overnight parking Vehicle wash <br /> I, / l , hereby state that the information I have provided is current,true and <br /> correct to the est of my know) e,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 shallify th EHDj�rrnvediately. <br /> Signature �' Date— <br /> 3 To'`be com leted b . the_ EALTH`='urisdictlon outside of.-San Joa uin 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 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br />