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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 />Date <br />Date <br />Date REHS Signature. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1868E Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 1 F 209 464-0138 | www.sjgov.org/ehd <br />SAN JOAQUIN <br />COUNTY <br />r^Electrical hook-ups <br />o<<roilet and handwashing <br />c^Potable water <br />t^Vehicle wash <br />City <br />j^Wastewater disposal <br />^sgjCSolid waste disposal <br />dB^ldot & Cold water for cleaning <br /> Store dry food/supplies <br />I, <br />operator fails to comply with the"conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall notifvAhe EHD immediately. <br />A- E=__________«=___/O-ZI--ZS__ <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. J <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 />Business Name £4 Lie. Plate# (p2R *7^31 <br />Owner/OperatorNam e^_______________________________ <br />Business Mailing Address H 1 ClH <br />City State CfoZiP %7JCS Bus. Ph.Alt. Ph. ZcX?~ 5(963 <br />I, toGO G* 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 penalties. <br />Signatute^xQlLr't Date-----------1 ----- <br />2. To be completed by COMMISSARY OWNER/QPERATOR <br />CommissaryName C qrfvti Cxl C o<pQVCcH p <br />Address 2-°l 00 ______Bus. Phone - Hug— <br />Zip Owner/Operator <S» 2.>GoV\tyn AvzocrW' <br />Check all appropriate services provided: <br />U^ds-compartment sink <br />1 J Food preparation <br /> Store refrigerated food <br />jXpvernight parking <br />, , hereby 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