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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 />Lie. Plate# <br />Date <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 />- SAN JOAQUIN <br />------COUNTY - - <br />Greatness a rows here <br />^r7)f l<^/V Zip U Owner/Operator PT/ T1 <br />Check all appropriate services provided: <br />3-compartment sink <br />jS^Food preparation <br />Store refrigerated food <br />JjS^vernight parking <br />A^Thereby stat< <br />knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />\ith4he conditions of this agreement, or if this agreement is modified or cancelled, the <br />ie EHD immediately. <br />1. To be completed by APPLICANT___________ <br />Business Name F F R \ _________________________ <br />Owner/Operator Name_FAK01 N'.gIZMA <br />Business Mailing Address V\/ V H A _________________________ <br />City Stat^SA Zip^ ^.^us. Ph5//M/)2~ W)$Alt. Ph. <br />I, f~7\ [2-07. A I 2 A b A . 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 />0. / 23 / 25 <br />2. To be completed by (^OMMISSARY OWNER/OPERATOR <br />Commissary NameHN/^N ___ <br />Address 11 l~] <5- U fJ / () _______Bus. Phonef if I (fl <br />Zip Owner/Operator OF/ N 5 T1 <br />Electrical hook-ups <br />M Toilet and handwashing <br />Potable water <br />Vehicle wash <br />ieTnformation I have provided is current, true and <br />Wastewater disposal <br />Solid waste disposal <br />Wj Hot & Cold water for cleaning <br />YL Store dry food/supplies <br />7 vef/Ra ffj <br />correct to the best/Ofm^ <br />operator fails to comply <br />commissary ownefskaU^o'’ <br /> <br />S i g n a t u <br />3. TcFfie 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.