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SAN JOAQUIN <br /> <br />Environmental Health Department <br />—COUNTY— RECEIVED <br />Greatness grows here. <br />MAR 14 2024 <br />COMMISSARY AGREEMENT ENVIRONMENTAL HEALTH <br />Mobile Food Facility. Caterer <br />DEPARTMENT <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />To be completed by APPLICANT <br />Business Name A 11 re_ `_.s c c44- -e r I <br />4 Owner/Operator Name Oon-e_ ch. <br />Business Mailing Address C2, C - Wox 11 a <br />City Li) (k ( f---..---6 State (.4") Zip 6--)L31 Bus. Ph( 2_ C.; '': ) btG.- 3 '-( 5-5 Alt. Ph.(Zoc )2-(-3 - 2 9" <br />I, (,10i07.clo teq- kkolyr‘c , 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, he permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penal? <br /> <br />Date .7 — LI Signature <br /> <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Cr, m al;.'.ssar y t-/ &ct //c) T pc- FA# <br />Address 3 (7_,S k) 6 LA i Id A--c c_ Bus. Phone a)q- --,-.3(/' ZE 2 <br />CA City Lod. ; Zip Owner/Operator A- I be ,(-1-c) - weirr (1 . 4,4 &t- it <br />Check all appropriate services provided: <br />54Wastewater disposal '3-compartment sink 7i Electrical hook-ups <br />1:7Solid waste disposal 0 Food preparation -)a- Toilet and handwashing <br />1; Hot & Cold water for cleaning 0 Store refrigerated food *Potable water <br />0 Store dry food/supplies Overnight parking Vehicle wash <br />I, (--t. Je.,-V1 it,t c,r , L' 7_ ,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 shall notify the EHD immediately. <br /> <br />Date 3Zcc y Signature <br /> <br />To be cor1eted 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 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />PRost-itven- <br />Lic. Plate # L112 VC; 6:0