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Commissary Name <br />Address 6-U/Y v--e Bus. Phone 331- — <br />City 6a / Zip (-;c/0- Owner/Operator <br />Check all appropriate services provided: <br />To be completed by COMMISSARY OWNER/OPERATOR <br />4.)/-7-/Av .1(Q/ 6'4,4 FA# <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY - <br />RECEIvED <br />COMMISSARY AGREEMENT MAR 2 52025 Mobile Food Facility. Caterer CNviitoNwiviA4 <br />HEALTH <br /> <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also iMptRi'mVsnr.s. - _ . <br />To be completed by APPLICANT <br />Business Name Pan A:\ s &Tw ice _ S61-_k_ Lic. Plate #Likkic,G,1 -7 2- <br />Owner/Operator Name 40 otiA.) r otr-z& <br />Business Maling Address titi_ tik..--.:ct. I ow Lri , <br />City tjC I State (A Zip 9S-D1/0 Bus. Ph.530 -9,9-1-7W11 Alt. Ph. c.407-6-irg----C-C-S7 <br />- <br />Wastewater disposal <br />Solid waste disposal <br />Fi Hot & Cold water for cleaning <br />0 Store dry ford/supplies <br />/4(i-ec <br />4C 3-compartment sink <br />Food preparation <br />Store refrigerated food <br />pir Overnight parking <br />, hereby state that the information <br />pl Electrical hook-ups <br />Ejt Toilet and handwashing <br />Potable water <br />0 Vehicle wash <br />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 />otify t ediately. <br />Date <br />Greatness grovis here. <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 END. Failure to notify this office may result in permit <br />revocation and pe ties. <br />Signature Date <br />commissary owner sh <br />Signature <br />3. To be completed by the V 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 />P1209-1 gg,