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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 />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />Date REHS Signature, <br />/ z <br />2. To be completed by COMMISSARY OWNER/OPERATOR <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 />FA# <br />Bus. Phone '<247/| <br />Owner/Operaton RlWirvIPlCl <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 />?^2500S2 2_ <br />SANJOAOUIN <br />-COU NTY- <br />Greatness qrows here <br />io <br /> Electrical hook-ups <br /> Toilet and handwashing <br />Potable water <br /> Vehicle wash <br />Commissary Name IjOUSE df (GOrf't <br />Address_ <br />City MX) |Zip <br />Check all appropriate services provided: <br />0 Wastewater disposal J^3-compartment sink <br /> Solid waste disposal Food preparation <br />Hot & Cold water for cleaning Store refrigerated food <br />J3^fetore dry food/supplies Overnight parking <br />I. 0 , 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 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 ^fa^l^notifyjhe EyHp immediately. <br />Signature • Ift- 2-5 <br />1. To be completed by APPLICANT_____ <br />Business Name, <br />Owner/Operator NameTkA’CY' KjQVA CAZkfd> <br />Business Mailing Addressx)2,\ <br />City LoAi Stated Zip ^5W Bus. Ph.0J^4OO Alt. Ph. <br />■ hereby state that the above information is current, true and correct to <br />the bLst 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 and penalties./ <br />Signature! I/}/Date ‘ / / L