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Environmental Health Department <br />-s- <br />Date <br />Date <br />I www.sjgov.org/ehd <br />Electrical hook-ups <br />Toilet and handwashing <br />IQ^Potable water <br />Ef Vehicle wash <br />.u ... o c > current, true and <br />---------la Health & Safety Code requirements. If the food facility <br />agreement, or if this agreement is modified or cancelled, the <br />Margot <br />1868 E. Hazelton Avenue | Stockton. California 95205 | T 209 468-3420 | F 209 464-0138 <br />SANJOAQUIN <br />-----COUNTY------- <br />C.-?a.-n.3S5 r.-l.,erC <br />--------County. The above food facility meets the <br />The above checked services are available at the <br />3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />Overnight parking <br />:orrect to thSbfsf of my ionf°mation 1 have Provided is ;.uo allu <br />morof^r * ’ a forma Health & Safety Code requirements. If the food facility <br /> ~ Date c <br /> ^P'TedTyCOMMrsYARYOWNER^/OPERATOR <br /> Commissary Name brill,-,__________FA# <br /> <br />Phone <br /> ty ~---------------------p—0 Qwn e r/Op e rato r <br />Check all appropriate services provided: <br />Wastewater disposal <br />13^Solid waste disposal <br />l^Hot & Cold water for cleaning <br />n Store d^fpod/suppIies <br />c< ‘ <br />operator fails to comply with the conditions of thV{ <br />commissary ownershall notitythe EI^Kmmediately. <br />Signature - <br /> <br />The commissary is located in <br />Code, <br />commissary. Please notify EHD if the status of their operating permit changes. <br />REHS Signature <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer <br /> <br />TJg^becompfetecTbyAPPLICANT ------------------------------------------------- <br />Business NamT / cI-, 11 ? y-x <br />n ------------------------------------------Lic.Plate# <br />Owner/Operator Name^^ V y <br />Business Mailing Address, /q^q u ^v- <br />CHy-^ULMcV^StateOyzip V^Q Bus. Ph. g, , . A|t ph <br />the ab0Ve inf°™ation is curreTTZTTTTo <br />Safety Code, and San Joaquin County Env ronmental Health C°'T1rn'ssary( ln ^c°rdance with California Health & <br />commissary is discontinued, the permitholde “must no iN the PHD T, ( 1 rec'uiremente- * use of the <br />revocation and penalties;"Y> EHD' Failure ,0 notify this office may result in permit <br />Signgturg"' '—-------- <br />[2. To^e