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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 />// <br />DateSignature <br />Date <br />Date REHS Signature. <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 />E^S-compartment sink <br />eTFood preparation <br />Store refrigerated food <br />□^Overnight parking <br />SANJOAOUIN <br />-----COU NTY------- <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 />1. To be completed by APPLICANT___________■_________ <br />OSCA/P /CE Lie. Piate# <br />Owner/Operator Name_ S'ccAZO O2.CZAK <br />Business Mailing Address ( 2-' F? -S' 1 F~ <br />City ^State Zip^C?^ Bus. Ph^-?2.S6ud?Ait. Ph. <br />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, thfe permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and 2-^ <br />City- <br />Check all appropriate services provided: <br /> Wastewater disposal <br /> Solid waste disposal <br /> Hot & Cold water for cleaning <br />-rf^Store dry food/supplies <br />2. To be^ompleted by COMMISSARY OWNER/OPERATOR_______________ <br />^rvN.ne <br />Address_ zE — /jl/cBus. Phone 3 H <br />ziP ^<^s%wner/Qperator <br />□x^fectrical hook-ups <br />H^Toilet and handwashing <br />□^Potable water <br />Vehicle wash <br />I, 3 C2- iRrJiereby 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 / , / yf/C <br />Sign atyifi-:^___________________________D a te