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Environmental Health Department <br />Business Name <br />Alt. Ph. <br />Date <br />^complete3.Tofa <br />DateREHS Signature <br />IThFiTT? <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> <br />1. To be completecfeb^B^dj <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 AGREEMENT <br />Mobile Food Facility o Caterer <br />1868 E. Hazelton Avenue | Stockton. California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />0545^1^ <br />Owner/OperatorName 'f i < <br />Business Mailing Address/< ftp- <br />State ^S*Zip . <br />i .S C h <br /> Lie. Plate # <br />City_ State d Zip >^gus Ph <br />I. IJS C hereby state that the above inrormafion 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 />Signature 2________________________________Date <br />SANJOAQUIN <br />-COUNTY------ <br />:: .It.'ir;:-. here. <br />Wastewater disposal <br />§3^ Solid waste disposal <br /> Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I. <br />correct to the best of my knowiedgepa <br />Date 7^/ <br />2. To be comp^t^by^CBl <br />Commissary Name_L FA# ’002. <br />Address_ __Bus. Phone JZd?- 7Z2-- <br /> City hrr>|O Zip Owner/Operator <br />Check all appropriate services provided: f <br /> 3-compartment sink CB Electrical hook-ups <br />□ Food preparation ffl^oilet and handwashing <br /> Store refrigerated food Potable water <br />B^Ovemight parking □''Vehicle wash <br />, hereby state that the information I have provided is current, true and <br />correct to the best of my knowiedgefand 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 ownertshall nptifyThe EHD immediately. <br />Signature Iry *—