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Environmental Health Department <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Lie. Plate # <br />Alt. Ph. <br />Date <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />Date <br />G? Electrical hook-ups <br />E2 Toilet and handwashing <br />p Potable water <br /> Vehicle wash <br />0 3-compartment sink <br />0 Food preparation <br />pT Store refrigerated food <br /> Overnight parking <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />-------COUNTY <br />Greotness gr <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />OOS <br />here. <br />Date Q'X <br />1. To be completed by APPLICANT__________ <br />BusinessName O-V\ V-* T^~6c\ qS <br />Owner/Operator Name „ i Q <br />Business Mailing Address 'Z, \ "Z- (A ca ____________ <br />City je-Fo(\ State^cy Zip^AZL// Bus. 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 />S i g n atu re.^Xx^*-^ <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, JI <br />2. To be completed by COMMISSARY OWNER/OPERATOR_______________ <br />Commissary Name_FA# <br />Address , C- L/ i [d fi t -_____Bus. Phone C' fop, <br />City / zZTV Zip 9^/^ _Owner/Operator_ ^T/^t/ d-tvz /. tc//^ / <br />Check all appropriate services provided: <br />p Wastewater disposal <br />Solid waste disposal <br />p Hot & Cold water for cleaning <br />tS Store dry food/supplies <br />I, C. \r\rl i~, 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 no^fvthe EHD^immediately'/ / <br />Signature Date