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Environmental Health Department <br />Complete sections 1 and 2. <br />Date <br />□Electrical hook-ups <br />□/Toilet and handwashing <br />□^Potable water <br />□□Vehicle wash <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />SAN JOAQUIN <br />------COUNTY— <br />Owner/Operator <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />If your commissary is located outside of San Joaquin County also complete section 3. <br /> <br />/LTo be completed by APPLICANT <br />Business Name <br />Owner/Operator Name_7/>qfl <br />Business Mailing Address <br /> <br /> Zip ySB^/Bus. Ph. 7^,5'?/yAit Ph. a/ <br />-----------hereby state that the above information is current, true and correct to * ------------------------ <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. <br />■ z> »J! a _ — x! I < I •. ■ ■■ <br />revocation and penalties. » j <br />Sig natu re vs fl/\ <br />Lie. Plate# Ken C/W <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 />rthe Permit h°lder mUS| n°tify the EHD- Failure t0 notify this office maV result in Permit <br />,Date o8' 06- 2,0 2.^ <br />[2. To be completed by COMMISSARY OWNER/OPERATOR^ <br />Commissary Name-^TgC/dTob/"T /Cfc CC^^/vlFA# <br />Address Z^/ _________Bus. Phorle o^O^- <br />City cS>7^C<<cTPaJ Zip^S^t)^ <br />Check all appropriate services provided: <br /> Wastewater disposal il/S-compartment sink <br /> Solid waste disposal O Food preparation <br />‘ Hot & Cold water for cleaning □'"store refrigerated food <br />/Tstore dry food/supplies □''Overnight parking <br />C2 f-fo U N) , 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 /> ______ Stpckton, uatfomla»5205 f ~— <br />3. To be completed by the ENV HEALTH jurisdiction outside 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