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Environmental Health Department <br />Date <br />FA# <br />Date <br />REHS Signature Date <br /> Electrical hook-ups <br />X Toilet and handwashing <br />"X Potable water <br />^■Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1868 E. Hazelton Avenue | Stockton, California 95205 [ T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />SAN JOAQUIN <br />COUNTY----- <br />jnditions of this agreement, or if this agreement is modified or cancelled, the <br />HD immediately. <br />Address |"] 17 3 - 0 AJ * 0 <br />City 370 uc-fo rO Zip Q, <br />Check all appropriate services provided: <br />X- Wastewater disposal <br />X Solid waste disposal <br />X Hot & Cold water for cleaning <br />Store dry food&upplies <br />i, QOS <br />correct to ” ’ <br />operator fails to conu <br />commissary ownefsh; <br />Sign ature <br />3. To 6e 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 />3-compartment sink <br />Food preparation <br />X Store refrigerated food <br /> Overnight parking <br />_____hereby state that the information I have provided is current, true and <br />to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <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 />Business Name^A1 ft Q^l 7^ ft Lie. Plate# G <br />Owner/Operator Name W-OAVCAr______ft] a.\ ____________________________________ <br />Business Mailing Address K C 1^- <br />City State CAZip Bus. PhA^IV^SSH Alt. Ph. <br />i. lAjintcTX , 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 penalties. <br />Signature -Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name I) A JI (7X1 C I kJH T^(/UC Co.rh^X <br />S7_____________Bus. Phone A <br />Owner/Operator