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Environmental Health Department <br />Lie. Plate # <br />Date <br />209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd1868 E. Hazelton Avenue | Stockton, California 95205 | T <br />Wastewater disposal <br />0 Solid waste disposal <br />zd Hot & Cold water for cleaning <br />Store dry food/supplies <br />SANJ0A0U1N <br />-----COUNTY------ <br />Greatness grows here. <br />Electrical hook-ups <br />Toilet and handwashing <br />Q Potable water <br />Vehicle wash <br />hereby state that the information I have provided is current, true and <br />- • ■ ‘ i. If the food facility <br />■ cancelled, the <br />Signature QVxJv L__---------------------- ------------------------------ - ” <br /> <br />3. To. be completed by the ENV'HEALTH jurisdidibh .outside oRSan Joaquin Co, <br />• 1 + H in County. The above food facility meets the <br />“JJX-™ “n— - ■«*» •» ■' - <br />above Gonrates.iy Plaaaa aoWEHDIftheatatoaotthairop.^ng pormaobabsoa. <br /> REHS Signature-------------------------Date, C ' /O----------------- <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 /> <br /> 11, To be completed by APPLICANT —-----------1 <br /> <br /> Business Name^4o'T5 ^5 —M <br />Owner/O perator-Name f 3 -------------- ---------------- ------------------- <br /> Business Mailing Address/^ 7 /.J ------------------------------------------------- <br /> City /> W u/^4*6tate C qZip_gZ65£rBUs. Ph.jS^Z, Ph.5^ JC- <br />I f c f , hereby state that the above information is current, true and correct to <br />the best of my krfowledge 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 />fommissa^s discontinued" the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties^_ <br /> <br />Signature <br /> <br />[ 2. To be competed by COMMISSARY OWNER/QPERATQR <br /> <br /> Commissary NameJ^MA C (X( f C) <br />Address. U-KI -__Bus.pho^llbdl 7TJU <br />City T4CK ZipO.TUC) 6 Owner/Operator \ JU Qi \ CC.jU- <br />Check all appropriate services provided: <br />0^3-compartment sink <br />0 Food preparation <br />Store refrigerated food <br />Q Overnight parking <br />\ X CP \ C\ hereby state that the information I have provided is cl <br />coTrectYo t e best of my kfedge, and the California Health & Safety Code requirements. If 1 <br />opeX fails to comply with the conditions of this agreement, or if this agreement is modified or <br />commissary owner shall notify the EHD immediately. / <2 /<q ( I <br />Signature Date SXWA