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Environmental Health Department <br />Lie. Plate # <br />fa) <br />Date <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 />EfSbilet and handwashing <br />Notable water <br />^Vehicle wash <br />■SAN JOAOUIN <br />------COUNTY------ <br />Urectneii •row her<?. <br />3-compartment sink <br /> Food preparation <br />O Store refrigerated food <br />n/bvemight parking <br />. hereby state that the information I have provided is current, true and <br />-.y-------- ------------- 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 <br />3. Ter be completed by the ENV jjjgACTH jurisdiction outside of San JoaCjuift 6b. <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 />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1. To be completed by APPLICANT r <br /> <br />TA LT-ez <br />Business Name___I <br />Owner/Operator Name <br />Business Mailing Address VC/lAlS fKX, <br />City fan State 6/VZip Bus. Ph. Alt. Ph. <br /> ’hereby state ,hat,he above information is "■,rue and correct to <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements <br />pAmr-ntornm tr* _____i if. . •. ■ ■ ■ ___ ' • ' <br />revocation andoenalties. f\ <br />Signature. <br /> 2. To bez completed by( <br />Commissary Name| <br />Address 3SS N <br />City_ IxrL_______zip q52MD <br />Check all appropriate services provided: <br />^Wastewater disposal <br />SKSolid waste disposal <br />^Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I’-----------, iicicuy otaic mat me iinuifiidiiutt j nave pruviaeu IS <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. <br />Ige and agree to_utilize my approved commissary in accordance with California Health & <br />, . . . - - - ----- x4*"1 id no, 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 andoenalties. I \ • <br />O.,. <br />COMMISSARY OWNER/OPERATOR - WWFl <br />fGfi/Jn fa# <br />_______Bus. Phone <br />Owner/Operator