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Date <br />Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 [www.sjgov.org/ehd <br />_Lic. Plate # <br /> Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />Vehicle wash <br />Environmental Health DepartmentSANJOAOUIN <br />------COUNTY------ <br />■ 'ness 'i/-ow 7ere. <br />-! <br />3. To be completed byjhe <br />The commissary is located in <br />commissary requirements in California Health & Safety Code, <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />REHS Signature, <br />_FA#- <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o 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 <br />Business Name'^x^e. C <br />Owner/Operator Name \Cc_^z < <br />Business Mailing Address. qjl S iMohM V <br />City.Ud i______State^/l Zip^J(/L) Bus. vkyCT))')i 7 Ph. <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 />revocation and penalties?. <br />Signature<__^-^^jS <br />best^of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br />. - -n-x-------, ------------ - If the use of the <br />r °^TJi^lSwd'SCOminiied’lhS Permit h°lder mUSt nOt'fy the EHD’ Failure t0 r,otify this office may result in Permit <br />----------------------------------------------------------------Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR | <br />Commissary Name <br />Address------,// tr(ji Al/e. Bus Phone <br />City_ Zip Owner/Operator <br />Check all appropriate services provided: <br />lX 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 />and meets the California Health & Safety Code requirements. If the food facility <br />------J or cancelled, the <br />7-sO^c <br />jgL Wastewater disposal <br />Solid waste disposal <br />’JST Hot & Cold water for cleaning <br /> Store dry food/supplies <br />i.__At <br />correct to the best of my knowledge <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified <br />commissary owner shalHjptify theTHD immediately. <br />Signature. <br />HEALTH jurisdiction-outside of San Joaquin Co. <br />County. The above food facility meets the <br />The above checked services are available at the