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'SAN JOAQUIN Environmental HeattliDepartment <br />COUNTY iiECEIVED <br />Greatness grows here. <br />JUL 2 6 2024 <br />COMMISSARY AGREEMENT <br />Mobile Food Facility * Caterer <br />ENVIRONMENTAL HEALTH <br />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 1.4///Vtri/2/ ...TY- (.1 Lic. Plate # Lf V (L 7--‘s (4 <br />Owner/Operator Name //Ai/T-6 <br />Business Mailing Address 1,/t" 1 <br />City 7.-j7ktr Statii4- Zip rt3 3 )7- Bus. Ph(?i) / -}--(=',7?-- Alt. Ph. A.,/ if- <br />.. <br />c-- hizA) 4 c.) , 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 an Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br />commissary is di ontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and <br />SignatureY elte, <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name C orAm; ssck,,,i i 1 (pit I/O TAK., FA# bog- slq--I/ 5 0 <br />Address 355 )3 • Gm.t'lci Au c_ Bus. Phone 7,0c/‘ -.c.C-f-- 1 15 73 <br />City (...0c,1 C. Zip ciSZ Li 0 Owner/Operator M 10 #c. Ak_C•rt ci-e_ 7- <br />Check all appropriate services provided: <br />14 Wastewater disposal <br /> <br />*3-compartment sink <br /> <br />t?‘ Electrical hook-ups <br />*Solid waste disposal <br /> <br />0 Food preparation <br /> <br />fr Toilet and handwashing <br /># Hot & Cold water for cleaning 0 Store refrigerated food <br /> <br />0 Potable water <br />0 Store dry food/supplies -fg Overnight parking 7L Vehicle wash <br />I, boe.,,Av AkcArtv-t--r--- , hereby state that the information I have provided is current, true and <br />correct to thekest 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 noy the EHD immediately. <br />Signature <br />To be cáipleted 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 />W6L-IB2-1 <br />C <br />Date <br />Date 7- /0-7czcif