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e o t n e s s <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />0^12)100,5'Date <br />City.Owner/Operator <br />Vehicle wash <br />Date <br />Date REHS Signature. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <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 />3-compartment sink <br />Food preparation <br /> Store refrigerated food <br /> Overnight parking <br />, hereby state that the information I have provided is current, true and <br /> Electrical hook-ups <br />Toilet and handwashing <br />H Potable water <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />COUNTY <br />here. <br />________ <br />3. Tdffie completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />2. To be completed by COMMISSARY OWNER/OPERATOR______________ <br />Commissary Name \)N I ON _ <br />Address nn 5- \jmon tt ___Bus. Phone iqr- shi is <br />STbCK-TAN Zip ^Owner/Operator I^SlPENe TIPixpo <br />Check all appropriate services provided: <br />[^(Wastewater disposal <br />hf Solid waste disposal <br />Hot & Cold water for cleaning <br /> Store dry food/supplies <br />.. X|F5IKA <br />correct fo the best oCnyknowledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to complyJWTpe conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary ownpJ)^11alHroJ^qhe EHD immediately. <br />Signatu Fe <br />Lie. Plate# <br />yrovvs <br />1. To be completed by APPLICANT _____ <br />Business Name JK I Mt* F 'T <br />Owner/Operator Name <br />Business Mailing Address I04K 5- CtMVP- ST <br />City S YD Cj^TD |\( State Zip Bus. Ph. J333Alt Ph <br />iT-hfML JAliVkf A COm , 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, k) A — <br />S i g n a t u re_____________fl <br />Environmental Health Department <br />>IFA . <br />;t to the best ofTny" <br />air