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Environmental Health Departmenti: <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Date <br />-1 -Date <br />Date REHS Signature. <br />Commissary Name_ <br />Add ress <br />City <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SANJOAOUIN <br />------COUNTY----- <br />Greatness grows here. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />tJ Electrical hook-ups <br /> Toilet and handwashing <br /> Potable water <br /> Vehicle wash <br />< <br />OxT~7__ <br /> 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />P^Overnight parking <br />A thereby state that the information I have provided is current, true and <br />Lie. Plate # Q <br />1. To be completed by APPLICANT_______ <br />Business Name C\4iZ_ EAj' <br />Owner/OperatorNam e ________ <br />Business Mailing Address SeCaA/A CiC <br />City State ft-Zip^5j£LX Bus. Ph. 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 and penalties. <br />Signature * <br />2. To be completed by COMMISSARY QWNER/OPERATOR <br /> fffol /J. (kUrcf Lc_______fa# <br />______________________________Bus. Phone PcGlpl - <br />Zip Owner/Operator <br />Check all appropriate services provided: / <br /> Wastewater disposal <br /> Solid waste disposal <br /> Hot & Cold water for cleaning <br /> Store-dry food/supplies1,^ <br />zc^irect 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 EHg) immediately. <br />S i g n a t u re_______ <br />3. T(r6e 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.