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SAN JOAOUIN Environmental Health Department <br />I <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Date <br />2 To <br />REHS Signature.Date <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 />Electrical hook-ups <br />jLToilet and handwashing <br />ST. Potable water <br />/Kl Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />1868 E. Hazelton Avenue Stockton. California 95205 I T 2C9 468-3420 | r 209 464-0138 lwww.sjgov.org/ehd <br />p Wastewater disposal <br />£32 Solid waste disposal <br />’^Hot & Cold water for cleaning <br /> Store dry food/supplies <br />i, voSeu <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. . <br />Signature Date ‘ /O <br />rOWNER/OFERali <br />CommissaryName CO(Y\(V\_______FA#__________________ <br />Address SQCGW\(7At<C Bus. PhoneQZO^ 2ZU -P) 33 <7 <br />City Zip Q Owner/Operator CCV\CCl <br />Check all appropriate services provided: <br />^k3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />^Overnight parking <br />L, hereby state that the information I have provided is current, Vue and <br />correct to the best of my’knowledge, and meets the California Health & Safety Code requirements. If the foockfacility <br />■______________, ■ • I <br />Business Name Lie. Plate# H)/N ~7Iu3 <br />Owner/Operator Name <br />Business Mailing Address S&i P^tnc^ Ct , SiOOphJn Zd <br />City ‘FAtZlL-tbA State <9VZip Bus. Ph. - M 01 - G?/Alt. Ph. <br />I. /VWl.UT^ , 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 oenalties^^ <br />Signature