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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 />3 3^2^Lie. Plate # <br />-7- 2.3-'ZSDate <br />7 - T-g - SDate <br />Date PENS Signature <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'ehd <br />City <br />Check all appropriate services provided: <br />3-compartment sink <br /><C*LFood preparation <br /> Store refrigerated food <br />/^Overnight parking <br />^/^Electrical hook-ups <br />J^Toilet and handwashing <br /><>4 Potable water <br />oZ. Vehicle wash <br /> , hereby state that the information I have provided is current, true and <br />correct-t&Yhe best of my'knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />FA# <br />1. To be completed by APPLICANT <br />Business Name_ APt'S -Too 4s <br />Owner/Operator Name <br />Business Mailing Address L~['l \ <br />City State Zip 1 Bus. Ph. Alt. Ph. <br />I a. < ^ftereljy 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 penalties. f <br />S ig n atu re < /A i- i <br />/ji Wastewater disposal <br />Solid waste disposal <br />.pPHot & Cold water for cleaning <br /> Store dry food/supplies <br />I. Va.M PcaiTTvtus <br />correct ■to'tl' <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 EHDJmmediately. <br />S i g n a t u re_________y_____ <br />3. To be corrTpleted by the ENV HEALTH jurisdiction outside of San Joaquin Co. <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 />2. To be completed by COMMISSARY OWNER/OPERATOR <br />CommissaryName ]^u Ca<\p' <br />Address Bus. Phone <br />5 H Zi p 0^ 2 o oWner/Operator •