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Environmental Health Department <br />~~7]; <br />Ho M262- <br />Date <br />- <br />Date <br />REHS Signature Date <br />■'£[ 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />S^Overnight parking <br />Lie. Plate # <br />G| H O 'roQrs <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ❖ Caterer <br />If your commissary is located outside of San Joaquin County also complete section 3. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />SANJOAOUIN <br />------COUNTY------ <br />’ Greotnes^ grows her:-- <br />_____________FA#________________________ <br />Bus. Phone^2~£?ct_\ __________ <br />Owner/Operator G ■ <br /> Alt. PhCgloj 37^-6^30 <br />above information is current, true and correct to <br />agree to utilize my approved commissary in accordance with California Health & <br />•. -.......--------------------------..................... Vu.. .^uiicmciuo. If the use of the <br />commissary is discontinued.lhe permit holder must notify the EHD. Failure to notify this office may result in permit <br />---------nd penalties^ “ Q J/) <br /> Date -. <br /> <br />o be Completed by COMMISSARY OWNER/OPERATOR <br />Complete sections 1 and 2. <br />LljEli^pletedT^APPLJCATfr <br />K-esCcv- Bet <br />K * f ( <br />/’ F ' O <br />.■7 rT!r a !<>•'■ <br />/ <br />Commissary Name ■ r> <br />Address 2-^1 CO <br />City Zip <br />Check all appropriate services provided: <br />tl Wastewater disposal <br />E] Solid waste disposal <br />J^Hot & Cold water for cleaning <br /> Store dry food/supplies <br />M Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />Vehicle wash <br />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 shallpotify the EHD immediately. <br />Signature _____________________________-Date________'! <br />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 />Business Name <br />Owner/OperatorNam e K ( S i <br />Business Mailing Address I Q Sn, fvx <x\ <br />City StateQW Zip^jgBS^ Bus. Ph. <br />i. k; rTxkn-^-3 K hereby state that the <br />the best of my knowledge ana agree to utilize my approved comr j <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. <br />revocation and pen <br />Signature