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revocation and p <br />Signature <br />1 , <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility , Caterer <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 /><170 (h )ejl t) ) Lic. PI ate # Business Name H .-1/ 612 <br />Owner/Operator Name 0 *t P\( /14(-S <br />Business Mailing Address \f3 U`-3-C:5- <br />City cl-\)( n <br />State Zip 7.63 Bus. Ph.7(31-1(1-52'57CV-r Alt. 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 disco t d, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />C 0 11 N I <br />Greatness grows here. <br />STANISLAUS COUNTY <br />DEPT OF ENVIRONMENTAL RESOURCES <br />RECEIVED <br />JAN 31 2024 <br />Date / 11- <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name /16or, lOcivn /Z( <br />FA# <br />.-13 Address 0...\\ S. iv" 9- <br /> <br />Bus. Phone (20038 -366 3 <br /> <br />City pto cA Zip '1535( Owner/Operator (.);114,41 gerk o ; <br />4 Check all appropriate services provided: <br />J <br />ErWastewater disposal 04-compartment sink <br /> <br />Erilectrical hook-ups <br />ErSolid waste disposal D400d preparation4 <br /> <br />El :-Toilet and handwashing <br />Store refrigerated food <br /> <br />0,15-otable water <br />Overnight parking 04ehicle wash <br />I, Lis 6116- , 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 hall notify the EHD immediately. <br />Signature Date <br /> <br />To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in ,C 1 a LL,..s 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 />J . [3:72 cL&Q4 FS •,4-4?( (1_5 <br />//426-7 y <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />13 -Hot & Cold water for cleaning <br />C4-f 0 Store dry food/supplies <br />REHS Signatur Date <br />Po63-kick(0