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RECE <br />MAY 1 4 2024 <br />STANISLAUS COUNTY <br />DEPT OF ENVIRONMENTAL RESOURCES <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility. Caterer <br />ild0AQUIN <br />COUNTY-- <br />Greatness grows here. <br />- <br />9—Electrical IVIectrical hook-ups <br />13 Toilet and handwashing <br />12e Potable water <br />0 Vehicle wash <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 />Business Name ge RILL eaktie (bt <br />Owner/Operator Name .-k,e44/)d ,2 tibJQA/15 <br />Business Mailing Address A.5i K/'//71a2 e 7 <br />City leidaaang, State4Zip 9'4 ' Bus. Ph.21 Oqoilf,03 Alt. Ph.20Ak86 303 <br />I , 7016 4‘)/M <br />Signature Date <br /> <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name J6 yym. t ( cA;s. FA# ci '3 -if I oq 9. <br />Address ,.201 <br />City 0‘0 .=-:S TO Zip 4 .3-5 Owner/Operator 71,0.-c, <br />Check all appropriate services provided: <br />9/3-compartment sink <br />ci) Food preparation <br />a Store refrigerated food <br />pi Overnight parking <br />, 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 own r sha notify the E D immediately. <br />Signature Date 5---/41 <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in yFayi6 1.01,0 County. The above food facility meets the <br />commissary requirements in California Health & Safety Cod d. The above checked services are available at the <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />RENS Signature McCtur Date - <br /> <br />Lic. Plate # Ve37, Vs? <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 penaltie <br />Bus. Phone 9-oct t <br />Ei Wastewater disposal <br />d Solid waste disposal <br />Q Hot & Cold water for cleaning <br />Fr Store dry food/supplies <br />I, VAR.1141,Ltir <br />1868 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd