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SAN JOAQUIN <br /> <br />Environmental Health Department <br />—COUNTY- <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 />To be completed by APPLICANT <br />Business Name TU.) Clreaon 4- 114 D035 , Lic. Plate # ti \if v a? yy <br />Owner/Operator Name EV1 ri 9 u.e, E3 Q to Om <br />Business Mailing Address <br />Cityck-\i') StateCA Zip 9.___--,t5 Bus. Ph.;)09 (1.30-7a7,5Alt. Ph. OCsCi 18 0 rc:-1?-75, <br />1-,eneici cR_, Eol,-)a.,z{-\ F-(7i co , 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 and .en ,d - <br />vMS,10 ,4gr <br />Signature <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Bus. Phone aC)9 430-7R75 <br />Owner/Operator En ri\ 9,Q k, Eip?p3 oz_k Cr106 Cityc."\--011) CA. Zip 9 _5(:)9 <br />Check all appropriate services provided: <br />Wastewater disposal <br /> O 3-compartment sink <br />1:1 Solid waste disposal <br /> <br />O Food preparation <br />Hot & Cold water for cleaning 0 Store refrigerated food <br />Store dry food/supplies 0 Overnight parking <br />I,EryfloQQ, E5p'k er,72.0k , hereby state that the information I have provided is current, true and <br />correct to t -ie 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 o tify the EHD immediately. <br />Signature <br />3. To be L6ompleted 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 />RR 2L1 032M2 <br />Date 6/(1 /24 <br />Commissary Name FA# <br />Address gO(Dci gy cok DR <br />Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />Vehicle wash <br />Date Ortizq