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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 />Date <br />■ Date <br />Date REHS Signature.I— <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />SAN JOAQUIN <br />COUNTY <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehci <br />^Electrical hook-ups <br />J^Toiletand handwashing <br />Potable water <br />Vehicle wash <br />Commissary Name <br />Address <br />City <br />Check all appropriate services provided: <br />Wastewater disposal <br />Solid waste disposal <br />JzF-Hot & Cold water for cleaning <br /> Store dry food/supplies <br />i, IbaivnuS <br />L To be completed by APPLICANT__________ <br />Business Name_ A Pr "S <br />Owner/Operator Name <br />Business Mailing Address_ Ht I & <br />City <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />]^a CoY-oev-ct cA <br />3-^06 <?> vu0-^Bus. Phone <br />Zip Owner/Operator 6 ‘ <br />FA# <br />zy ____________________________ <br />State Zip Bus. Ph. 2^1 ^2-ZSSj, Alt. Ph. <br /> <- ^Tft'ereSy 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 apdoenalties. f ' <br />Signature <1-/|c-' nfltp <br />NkJ 3-compartment sink <br />O^-Food preparation <br />O Store refrigerated food <br />/^Overnight parking <br />. A yyxrT^VTUS . hereby state that the information I have provided is current, true and <br />correct^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“ Date ~7 ~ ------------- <br />AJobe completed by fhe ENV HEALTH jurisdiction outside of San Joagujn Cou <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.