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Environmental Health Department <br />■l <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Business Name <br />Date <br />ehicle wash <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 />□Electrical hook-ups <br />Epfoilet and handwashing <br />CKPotable water <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />’ SAN JOAQUIN <br />------COUNTY------ <br />Gregtness grows here <br />Lie. Plate # <br />1. To be completed by APPLICANT ________ <br /> <br />Owner/OperatorNam e <br />Business Mailing Address_ <br />City^ycEMo/x Stated Zip Bus. Ph.^C^S^^ 6Sco Alt. Ph. <br />l,^/5/"(S^/<3o 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. , r <br />S i g n a t u re D a t e 017//Z5 <br />2. To be^Completed by COMMISSARY OWNER/OPERATQR <br />Commissary Name 7 FA# <br />Address S Bus. Phone 'ZSL-'i <br />C ity x Zi p Own e r/O pe ra to r GRJ^1 <br />Check all appropriate services provided: <br />[^Wastewater disposal □^compartment sink <br />[UTSolid waste disposal (fi^ood preparation <br />Cl^Hot & Cold water for cleaning SEtore refrigerated food <br />□^Itore dry food/supplies DK^vemight parking <br />i, Ata-^____, 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 shall notify the EHD immediately. <br />Signature <br />3. To bTcompleted by the ENV HEALTH jurisdiction outside of San Joaquin CoT <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.