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Environmental Health Department <br />1 <br />-^33 1STH <br />/z- <br />REHS Signature Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br /> Electrical hook-ups <br /> Toilet and handwashing <br /> Potable water <br /> Vehicle wash <br />is current, true and <br />If the food facility <br />or cancelled, the <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAOUIN <br />------COUNTY------- <br />Greorness grows here. <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> <br />LLTo.be completed by APPLICANT ---------------------------- <br />Business Name_£-( MARCIANITO ICh Cgg/W _Lic. Plate#_2_Q| <br /> Owner/Operator Name Leond AAo<V\vA fiTraddo <br />Business Mailing Address^ST^^cLo/ctL^oQ^fYA^X <br />City STOCKTON <br />1 ■ L gon A MAftr; n G <x\cL_____,1 ', __:_____ ______ ____ ^UIICIK uuc dlK <br />LLLb®Si°LmLk?Tled?e and agree t0_utilize mV approved commissary in accordance with CaHfornia Health & <br />> ------------------ If the use of the <br />• yt permit holder must notify the EHD. Failure to notify this office may result in permit <br /> Date It- IZ~ ZjQ?^ <br /> <br />[2. To be completed by COMMISSARY OWNER/OPERATOR? <br />Commissary Name s—)rOCJTj^/J <br />Address <br /> <br />Bus. Phone_________________ <br />City. Zip Owner/Operator -SccPjg x/ <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 />i. L <br />correct tojhe best of my knowledge, and meets the California Health & Safety Code requirements. <br />commissary owner shall notify the EHD ii <br />Signature <br /> 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br /> Overnight parking <br />-C2-[-/~7/Lx(<7)br^l?ate that the information I have provided <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified <br />immediately. <br />________I Date I I <br />L To be comfflA^^^^eni^^l ^LTH jurisdiction outside of San Joaquin Co. <br />The commissary is located 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 />com <br />-State£4 Zip<l£2.0G Bus. Ph^O^^ftOlS Alt Ph. <br />G_Ltj»As1o------------, 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 />commissary is discontinued, tl <br />revocation and penalties. <br />Signature