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'I <br />Lie. Plate # <br />Date <br />-1\Z <br />____ <br />FA# <br />’ ■f'-—Z ux--------------------------------------------------, iiGicuy oioiu tnai uic 111 iui 11 id UOII I I lave piOVIUeU 15 <br />:orrect to the best of my knowledge, and meets the California Health & Safety Code requirements. <br />Date <br />Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />nZ^Overnight parking <br />fl^Electrical hook-ups <br />Ef*Toilet and handwashing <br />Bootable water <br />IS'Vehicle wash <br />. - Igeand agree to_utilize my approved commissary in accordance with California Health & <br />, , t b - ---- —"" • — ”■ •• ■» x**"1 *' f • vii i wi i iqi i co, If the use of the <br />r°^nJHnn^lddj!“?«™ed' the({>erm't holder nlust notifythe EHD- Failure to notify this office may result in permit <br />wi D.» ■t/f-f; <br />SAN JOAQUIN <br />------COUNTY------ <br />Greotness arows />ere. <br />Environmental Health Department <br />fZP2\Q-2£?i <br />Commissary Name| <br />Address, 35S N fc\j\\A <br />City_ . UrL zip ^5240 <br />Check all appropriate services provided: <br />^Wastewater disposal <br />Solid waste disposal <br />S^Hot & Cold water for cleaning <br /> Store dry food/supplies <br />••--------/O---------------------------------- 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 notifyjhe EHD immediately. <br />Signature Date 9 / Z9/Z-S <br />3, To be completed by the ENV jurisdiction butside 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 />REHS Signature <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Comp/ete seef/ons 7 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1- To be completed by APPLICANT <br />Business Name___Lit, p|ate# <br />Owner/Qperator Name fVoh. H L _____________________ <br />Business Mailing Address 3^9 pg/lfllS <br /> City.SdtjCfc'tOn StateC/VZip Bus. Ph. 20^ "325^7^^ Alt. Ph. <br />L, hereby state that the above information is current, true and correct to <br />the best of my knowledge and <br />V -J —r r - — • — — W. • •■ ■ ■•vw> J II i V4W/VZI MUI iw Will | k. <br />bafety Code, and San Joaquin County Environmental Health Department (EHD) requirements. <br />pHrnmironm !r* -J ai___ _____ ■■ ■ • • . ___ ____ ' ' ’ • . <br />revocation andpenalties. <br />Signature <br />2. To be competed Dy UOMIVIISSAKY OWNER/QPER <br />Bus. Phone_ <br />Owner/Operator