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Ws^Oo| <br />Environmental Health Department <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />I.Tobe <br />late #Business Name <br />Date <br />correct to the besTof my knowledge?and meets the California Health & Safety Code requirements. If the food facility <br />sd, the <br />Date <br />DateREHS Signature <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer - <br />2. To be complg <br />Commissary Name L A-tbr~oi <br />Address <br />Wastewater disposal <br />Solid waste disposal <br /> Hot & Cold water for cleaning <br /> Store dry food/supplies <br />i. <br />correct to the best of my knowledge^ <br />operator fails to comply with the conditions of this agreement, or if this agre< <br />commissary ownertShall noWytpe EHD immediately. <br />Signature <br />5 ^SOQwner/Qperator <br />Check all appropriate services provided: <br /> 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />ffif'ovemight parking <br /> ^#00^7^9.5 <br />Bus. Phone 7/ <br />City Ufid hrr>^>Zip 9,^ $*30 Owner/Operator ---------- <br />□(^Electrical hook-ups <br />Bl^Toilet and handwashing <br />Potable water <br />□^Vehicle wash <br />, hereby state that the information I have provided is current, true and <br />Trent is modified or cai <br />SiNJOAQUIN <br />-COUNTY------ <br />.'•.i f .■ q'ows ht?rc. <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 />C-2 <br />Owner/Operator Name_ <br />Business Mailing Address <br />City State 0^ Zip Bus. Ph. CfoS ^7 Alt. Ph. <br />I, /V) | €70 , 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 />Signature <br />3. To bbfcomi