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SAN JOAQUIN <br />—COUNTY <br />Greatness grows he , <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <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 '-VA01•1 Took c Lic. Plate # <br />Owner/Operator Name 1-kAAVQ. u,N • !Aar <br />Business Mailing Address '2 SS-S" ?:• <br />City1,-.Merup State 0.../4- Zip c/C3 c, Bus. Ph. SP -41-2,t Alt. Ph. S70-2.9 rt <br />-)01.1() k or3." , 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, he permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation an <br />Date 6/13/2024 <br />To be compleied-b. y COMMISSARY OWNER/OPERATOR <br />Commissary Name Stockton Community Kitchen <br />Address 110 N El Dorado Street <br />Bus. Phone (209)608-5455 <br />Signature <br />FA# <br />City Stockton <br /> <br />Zip 95202 <br /> <br />Owner/Operator Rima Barkett <br /> <br />Check all appropriate services provided: <br />Wastewater disposal <br /> O 3-compartment sink <br /> <br />Ca Electrical hook-ups <br />Solid waste disposal <br /> El Food preparation O Toilet and handwashing <br />Hot & Cold water for cleaning O Store refrigerated food <br /> O Potable water <br />Store dry food/supplies O Overnight parking O Vehicle wash <br />I, Rima Barket , 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 />the EHD immediately. commissary owner <br />Date 02/07/2024 Signature <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