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Environmental Health DepartmentSAN JOAQUIN <br />i <br />Date. <br />v-nv •J f, ;/.';I 2. To <br />r <br />Date' <br /> i <br />Date <br />r 20^464-0138 | www.sjgcv.org/erid <br />Commissary NameJ <br />Ad dress G?ZO SGCCCXY\(9 A'to <br />City LCtSX Zip ^52-50( <br />Check all appropriate services provided: <br />Wastewater disposal <br />^0 Solid waste disposal <br />"S^Hot & Cold water for cleaning <br /> Store dry food/supplies <br />o <br />1868 t. Hazelton Avenue Stockton. California 95205 I T 209 468-3420 <br />^3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />■^Overnight parking <br />i. ^z\era <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified <br />commissary owner shall notify the EHD immediately. <br />Signature-^^Date' <br />X Electrical hook-ups <br />^Toilet and handwashing <br />Potable water <br />X Vehicle wash <br />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 ;ood facility <br />t , x x,. ..... j or cancelled, the <br />H iunsgtcnon Joaquin Co. <br />The commissary is located in---------------------------County The above <br />“mm'ssan/ requirements m California Health & Safety Code. The above checked se^ices are avaLble at Jhl <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />REHS Signature <br />C.OWWMSWcA ---------FA#----------------- ------ <br />a /■ Rus. PhoneCZO^) 2^-833 V_____ <br />Owner/Onerator Ot-WX/t <br />COMMISSARY AGREEMENT <br />Mobile Food Facility * Caterer <br />> .»» =. »r»r —V » »»»• «' ’l“ <br /> <br /> ;U.MSS N„.-3-- «“=ABIin Tlx^- <br />Owner/Operator Name ~. . <br /> City SW-tS^ State ^Zip^l^Bus. Ph ^tOVHOHH^AIt. Ph..------------ <br />----nfSXSSSS!^® the best of my knowledge and agree to utilize my aPP^ove^grt~ (EHD) requirements. If the use of the <br />S&xxa J. A U -e. „ »=™ <br />revocation and cena!ties^_ <br />Signature