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Environmental Health Department <br />Date <br />- H - ^5'Date <br />REHS Signature <br />tX Electrical hook-ups <br />ISJ Toilet and handwashing <br />Potable water <br />Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer <br />Commissary Name <br />Address /20lOO <br />City <br />1868 E Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />' SANJOAOUIN <br />!.!■>% ... -COUNTY <br />Aff-,.,.?- <br />1 i, Grt’i. I jiCSi 11 • <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 />Signature <br />3. To be completed by -.he ENV HE/V TH /ii-isdiction 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 /> Date _____________ <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />i;:>?bwcbffipieted by Applicant . y n t <br />WUXtiAanLic. Plate # Business Name <br />Owner/Operator Name <br />Business Mailing Address I 0 0 <br />City \vrxc\-^n State t Zip 45^^ Bus. Ph.J Alt. Ph. - (q03 ^3^ <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 (si ____________Date-———------------------ -------------- <br />dOMMlSSARY OWNER/OPERATOR~ <br />La CorrtZ-rpi a,| ___________fa# <br /> <br /> lOCLvj______Bus. Phone <br />Zip S S S' Owner/Operator G-t t2-. "Otp1' J«2, <br />Check all appropriate services provided: <br />Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I,_____ <br />3-compartment sink <br />O Food preparation <br /> Store refrigerated food <br />Overnight parking <br />i hereby state that the information I have provided is current, true and <br />if this agreement is modified or cancelled, the