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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 />Business Name <br />4- <br />Date <br />Date <br />REHS Signature.Date <br />3-compartment sink <br />0 Food preparation <br /> Store refrigerated food <br /> Overnight parking <br />_Lie. Plate # </ V 6? ~7 0 <br />-------------------------------- <br />3. Tafegcompleted 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 AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SANJOAOUIN <br />-----COUNTY—- <br />Greatness grows here. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />Bus. Phone. '2-^- gey/ <br />K os i ru. Ti rZzryp <br /> Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />Vehicle wash <br />hereby state that the information I have provided is current, true and <br />correct tokhe best of my^knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />onditions of this agreement, or if this agreement is modified or cancelled, the <br />aFlD immediately. t In\\/l <br />.Owner/Operator <br />1. To be completed by APPLICANT___________ <br />Godi-ks Mi Mexico <br />Owner/Operator Name ' \t'\ <br />Business Mailing Address <br />City SH 0 (AC1 (f X) state CAzip S20(;Bus. Ph.__________________Alt. Ph.________________ <br />L^pS/?///7<C( \/^ 7 C hereby state that the above information is current, true and correct to <br />the best of my knowledge and agree 4o 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'pfenalties. j , . <br />Signature Date \ \ 1 V I 2^ <br />i 2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name kJr\ t <br />Address |A 5 <br />City yiOQtCtfl Kj Zip6 <br />Check all appropriate services provided: <br />gg Wastewater disposal <br />K! Solid waste disposal <br />PS Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I, \ psu<A Ste/v <br />correct tokhe best of i <br />operator fails to complySwil <br />commissary owner sfiajl nol <br />Sig natu re