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S A N.�J O A Q U IN Environmental Health <br /> i`.. —COUNTY— <br /> .r_.,, n <br /> U rBgtnc;s ge-uw,`here. <br /> JAN 19 2023 <br /> COMMISSARY AGREEMENT ENVIRONMENTALHEALTF11 <br /> Mobile Food Facility + Caterer DEPARTMENT <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 I f 7 <br /> Business Name I t! C Lic. Plate# Vl U <br /> Owner/Operator Name �91J f 1 ZL <br /> Business Mailing Address i cl L4 I V e g j& VJ <br /> City Tor k ToNState CAZip j 206 Bus. Ph.209-,30,9-2 9 02-Alt. Ph. <br /> I, 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 an alties. (n� <br /> SignatureDate�YP� <br /> 2. To be corn :leted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name &d l✓/h9 cr Ei( 4, 1�FA# <br /> Address /� � 14-i✓4/We s r� ) �` Bus. Phone <br /> City Cd dl ,l Zip 7� 32 Owner/Operator zV ��1) <br /> Check all appropriate services provided: <br /> 'Wastewater disposal 0 3-compartment sink O-Electrical hook-ups <br /> q'Solid waste disposal 13 Food preparation WToilet and handwashing <br /> Hot & Cold water for cleaning 0 Store refrigerated food Pr Potable water <br /> 0 Store dry food/supplies [3 Overnight parking Vehicle wash <br /> I, /h ' , hereby state that the information I have provided is current,true and <br /> correct to the 6est 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 shall ,tify the HD i diately. <br /> Signature Date <br /> 3. To be completed by the = HEALTH jurisdiction outside of San Joa 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.sjgov.org/ehd <br /> FIZ05148201 S <br />