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t.u <br />Date <br />J <br />REHS Signature <br />209 468-3420 1 F 209 464-0138 I www.sjgov.org/ehd1868 E. Hazelton Avenue | Stockton, California 95205 | T <br />EnvironmenteS Health DepartmentSAN JOAOUIN <br />------COUNTY- — <br />pr-;:-; ■■ ■ ’ <br />Lie. Plate # 4 ^*1/ <br />12 Electrical hook-ups <br />B^Toilet and handwashing <br />C0' Potable water <br />DsA/ehicle wash <br />hereby state that the information I have provided is current, true and <br />Commissary Name <br />Ad d ress V2>O O .x~5> <br />City Lu^rrrvbrg. <br />^Wastewater disposal <br />Solid waste disposal <br />fi3/Hot & Cold water for cleaning <br /> Store dry food/supplies <br />co^tjSS H'ealth & Safety Code requirements If the food facility <br />".IT. rn ' ZX with the conditions of this agreement, or if this agreement is mod,fied or cancelled, the <br />notify the EHD immediately. j i <br /> ___Qt/JD _______________Date -------- <br />completed bythe ENV HEALTHjurisdictiQr1 outside of San JoaquinCo. J <br /> County. The above food facility meets the <br />are available at the <br />COMMISSARY AGREEMENT <br />Mobile Food Facility <■ Caterer <br />an?2^fy^ir commissary is located outside of San Joaquin County also complete section 3. <br />1. To be completed by APPLICANT --------------— I <br />Business Name <br />Owaer/Operator Name Shl^l^ 1 > 1>1.4d-i------------- <br /> Business Mailing Address 0 N l)Z <br /> CityAOVIVTU/M WZ_CAZip4^J_Bus. Ph-^^^-T^AIt. Ph..-------------------- <br />I A L I nJ 1 / N Ml ■ hereby state that the above information is current, true and correct to <br />the bZof 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./^/ n <br />_. . ><>/. A. Date I £'1 ---------- <br />Signature________----------------------------------------------- -—■---------------------------- ----- ' J <br />2. To be completed by_COMMISSARY OWNER/QPERATOR_------------------- <br />LZZb fa# <br />____■ __________ ___Bu s. P h o n e ArZS T <br />Zip A l-ftSg I Owner/Operator^LrAgr&tiaJg___ <br />Check all appropriate services provided: <br /> 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />QzOvernight parking <br />. . r 1 . . .f — w-< r-J <br />operator fails to comply with the conditions of this agreement, <br />commissary owne^haiyfiotify the EHD immediately. <br />Signature__ <br />I 3. To be <br />The commissary is located in -------------- . <br />commissary requirements in California Health & Safety Code. The above checked services <br />above commissary. Please notify EHD if the status of their operating permit changes. <br /> Date. \ O- OH - £.02-^