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Date <br />SAN JOAQUIN Environmental Heg r- tDdairrirignt <br />JUL 2 6 2024 <br />ENVIRONMENTAL HEALTH Mobile Food Facility • Caterer PERMIDSERVICES <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />I 1:Tobeikirripeted by APPLICANT <br />Business Name /4//A/Cr14/ 1 /-1 Lic. Plate # v(L144 0 Owner/Operator Name Sk ye_ itiinicr <br />Business Mailing Address c2 679- Cry-t.044._ <br />City_Lkaw___Statille Zip 76-3 :1+ Bus. Phr7/0K7-9-84,-?- Alt Ph. 4/71- I, 1rt kitn) 4-6 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 />revocation and . <br />commissary commissary Is diJ. ntinued, the permit holder must notify the END. Failure to notify this office may result in permit <br />Signature .41.,411( <br />t4,71r-'`ug Date <br />1 2:-To be dOmpleten by COMMISSARY OWNER/OPERATOR <br />Commissary Name C OWttvl 1' SSA./ I 611/0 T.AJC. FA# 7.01- -I/5 0 Address -;SS A. • ("*.dici Art.)-( Bus. Phone 7 07' el- Z 3 City LOCI 11 Zip '152. VC) Owner/Operator u-t• 7— _ Check all appropriate services provided: <br />'RS Wastewater disposal 3-compa rtmentriC sink ill( Electrical hook-ups <br />iff Solid waste disposal CI Food preparation S. Toilet and handwashing <br />Hot & Cold water for cleaning 13 Store refrigerated food El Potable water <br />13 Store dry food/supplies "tilr Overnight parking 112C Vehicle wash <br />I, L...)CikcIV AkcAr hereby state that the information I have provided is current, true arkl <br />correct to thebest 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 no the END Immediately. <br />Signature Date 7- - y <br />r3. To be C. • etecl b the ENV HEALTH jurisdietion outside of San Joaquin Co. 1 <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 El-ID lithe status of their operating permit changes. <br />RENS Signature <br />CCUN1 <br />COMMISSARY AGREEMENT <br />1868 E. Hazeiton Avenue Stockton California 952051 T 209 468-3420 F 209 464-0138 www.sjgov.orgiehd <br />Plq o s2_(-1