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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 />Business Name <br />Lod>23^-£^^'539^ <br />Date <br />FA# <br />ehicle wash <br />Date <br />■ r <br />REHS Signature.Date <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 />CKElectrical hook-ups <br />ETroiletand handwashing <br />EKPotable water <br />2 2.8 <br />Bus. Ph. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />SAN JOAQUIN <br />COUNTY-- <br />here <br />□ ^^compartment sink <br />UKFood preparation <br />O^Store refrigerated food <br /> ’dvernight parking <br />, hereby state that the information I have provided is current, true and <br />------- ------------- 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. \ i <br />Signature v ■\j0LWW) ______9ate_S M ____ <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />STOCKTON, CA 95203 <br />Lie. Plate# <br />1. To be completed by APPLICANT_____ <br />Owner/Operator Name _______ <br />Business Mailing Address_ Box <br />City Lod* State CiAc-Zip 52^ I Bus. Ph. ^0^7-7/ Z^T^^It. Ph. <br />f 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 hoj^er must_notify_the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />S ig n atu re. <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary <br />Address-------------------------- ---------------------------------------------Bus.P^ne.------ --------- ------------------- <br />City.Zip Owner/OperatorG^^ ()/ <br />Check all appropriate services provided: <br />□^Wastewater disposal <br />EpSrtfid waste disposal <br />□>f^t & Cold water for cleaning <br />□LSt'ore dry food/atipplies <br />correct to the best ol my know'