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• `A s(3 )3 <br /> SANsJ0AQU N Environmental Health De artment <br /> C O U N T Y--- p <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 11. To be com ideted by APPLICANT <br /> Business Name 5 Lic. Plate#9 M " j <br /> Owner/Operator Name_ SC-C4 V— �q S�- _ <br /> Business Mailing Address '�'7�— r [ir 10 . <br /> City l— State Zip_ 2 Bus, Ph.�p� 15 -53 3 Aft. Ph. <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 permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation a enalties. <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR _. <br /> Commissary Name N MI LVI[—t V[ G% <br /> Address v r - Bus. Phone C4 6 j <br /> CityA�� 1 V Zip_ S Z O Own er/O pe rator--9ffhe <br /> Check all appropriate services provided: <br /> XWastewater disposal )14 3-compartment sink 13 Electrical hook-ups <br /> XSolid waste disposal X Food preparation Toilet and handwashing <br /> T[ Hot & Cold water for cleaning Store refrigerated food ` Potable water <br /> © Store dry food/supplies Overnight parking Vehicle wash <br /> I, FSt �SA 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 falls to comply it h conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner s EHD immediately. <br /> Signature Date_- 2025 <br /> 3. To be46mpleted by the ENV HEALTH jurisdiction outside of San ,boa uin 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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgnv.orglehd J <br />