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Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Lie. Plate# Business Name <br />Date <br />J2. To be completed by COMMISSARY OWNER/OPERATOR <br />Date <br />Date REHS Signature. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />Environmental Health Department <br />AFz<o2 l zo <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />----COUNTY <br />FA# <br />Bus. Phone \ '*%>/[ <br />Owner/Operatort <br /> Electrical hook-ups <br /> Toilet and handwashing <br />Potable water <br /> Vehicle wash <br />3. To be completed 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 />Commissary Name IjOUjc Of 00^ <br />Address ^3^ <br />city zip <br />Check all appropriate services provided: <br />p Wastewater disposal j2^3-compartment sink <br /> Solid waste disposal Food preparation <br />Hot & Cold water for cleaning Store refrigerated food <br />^S^fetore dry food/supplies Overnight parking <br />i, d , 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 ^l^notijyjhe immediately. <br />Signature <br />1. To be completed by APPLICANT______ <br />^2 (jD^ee Cowman iA <br />Owner/Operator Nam <br />Business Mailing Address^ <br />City LoAi State Zip Bus. Ph. Alt. Ph. <br />, 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 holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />S i g n at u re___________[