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c� <br /> OAQUIN Environmental Health Department <br /> to UNT� <br /> MAC ,6. . Vx\V, � RECE l'.: ._ <br /> COMMISSARY AGREEMENT MAY 14 2024 <br /> Mobile Food Faciiit Caterer sTA�+isLAuscouKTr <br /> y DEPT OF EwPONMENTAL RESWRCES <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 Lic. Plate# ,� 9 <br /> Owner/Operator Name <br /> Business Mailing Address ` 7 e7 <br /> CityAVO&OK StateMZip Bus. Ph.2M.a Alt. Ph. �qYJ3 <br /> I, :7t/ ! ' 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 y� <br /> Signature Date f q- Z <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> `, <br /> Commissary Name J(,l Y\ MK(A tc f (YUCA2, FA# _LO�t S 9( y� <br /> Address ,2Q� mc} Ill SIB Bus. Phone ��- 5LI l <br /> City Zip �'�a� Owner/Operator [ - <br /> Check all appropriate services provided: <br /> ,p Wastewater disposal �V3-compartment sink C�Electrical hook-ups <br /> CS' Solid waste disposal C' Food preparation 13 Toilet and handwashing <br /> 0' Hot & Cold water for cleaning Q' Store refrigerated food a Potable water <br /> 'Store dry food/supplies �'Overnight parking h Vehicle wash <br /> I (i , 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 n tify the E D immediately. / <br /> Signature �' Date `�G� <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in 1- A County. The above food facility meets the <br /> commissary requirements in California Health & Safety Cod . The above checked services are available at the <br /> above commissary. Please notify <br /> ,EHD <br /> , if the status of their operating permit changes. <br /> REHS Signature C 6 Date �U <br /> 1868 E. Hazelton Avenue i Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 i www.sjgov.org/ehd <br /> ,S <br />