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SAN JOAQUIN Environmental Health Department <br />C0UNTv <br />COMMISSARY AGREEMENT AUG US 2021 <br />Mobile Food Facility • Caterer <br />rNyIRONMEtJTAL HEALTH <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin Count1.-W6T b%&VbVs(c9& 3. <br />1. To be com l�eted b APPLICANT <br />Business Name / /7C C 6-L PW 1W ?1%'LJ Lic. Plate # Ml S( o q <br />owner/Operator Name AfK t7og %SRA <br />Business Mailing <br />Citys%(tX_� f8ti� StateOl Zip ZaZti) 6 Bus. Ph(JO)5(4.3'/y Alt. Ph <br />I, F4A)65 a, &?&LA C Akf? , 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 C unty Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinu , th er 'i -holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and pe Ities <br />Signature Date I <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name <br />U &JI o N <br />Cfl��R1/ti� <br />T CLCt� <br />Address -17i ? .`l1 <br />kAtci;t <br />5T <br />Bus. <br />city, z2fi o cn zip .z o <br />Check all appropriate services provided: <br />M'Wastewater disposal 12�3-compartment sink <br />Cl/Solid waste disposal Food preparation <br />S -541 <br />t`,) T <br />l9IElectrical hook-ups <br />O Toilet and handwashing <br />G <br />GrHot & Cold water for cleaning C`7 Store refrigerated food [B"Potable water <br />CY/Store dry foop�plies C9 Overnight parking IldVehicle wash <br />716l ,0 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 owner stfall notify tpe EHD immediately. / / <br />M//A <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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />