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Environmental Health Department <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Lie. Plate# <br />WPS <br />Date <br />REHS Signature Date k <br />i <br /> Electrical hook-ups <br /> Toilet and handwashing <br /> Potable water <br /> Vehicle wash <br />l._ <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />COUNTY -- <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 />Commissary Name. <br />Address <br />City ‘'iroC^OlJ Zip^57.O5~ <br />Check all appropriate services provided: <br /> Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br />Store dry food/supplies <br />_________ <br />Date O'! | VI | <br />1. To be completed by APPLICANT <br />Business Name I OrA^\ V \ CX <br />Owner/OperatorName ' | 10 TMl <br />Business Mailing Address OhyP <br />CityJ^OcV-VoYN State fAZipQ<^? is Bus. Ph. H3 I IgflS Alt. Ph. <br />L_ C> (J , 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. <br />Signature I aQ <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br /> <br />fj' 4^$^ /Bus. Phone <br />_Owner/Operator J <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 />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 />commissary owner shall notify the EHD immediately. / j <br />Signature Date <br />I