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P (2. O "S M 'l~| cj <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />bounty also complete section 3.Complete sections 1 and 2. If yc <br />1. To be completed by <br />Plate# <br />Alt. Ph. <br />Date <br />] <br />Owner/Operator <br />Date <br />DateREHS Signature <br />1868 E. Hazelton Avenue I Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />(3 <br />fwt <br />ihaljjlDtr <br /> Electrical hook-ups <br /> Toilet and handwashing <br /> Potable water <br /> Vehicle wash <br />ion is current, true and correct to <br />rdance with California Health & <br />requirements. If the use of the <br />y this office may result in permit <br />Business Name <br />Owner/Operator Name <br />Business Mailing Address <br />City State_ <br />I________________________ <br />the best of my knowledge and e <br />Safety Code, and San Joaquin ( <br />commissary is discontinued, the | <br />revocation and penalties. <br />Signature _____ <br />Ji ira^'r <br />SANJOAOUIN <br />-----COUNTY------ <br />Greetness grows here. <br /> 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />jELOvernight parking <br />____________, hereby state that the information I have provided is current, true and <br />^wledgerand meets the California Health & Safety Code requirements. If the food facility <br />itlflhe^bonditions df^this agreement, or if this agreement is modified or cancelled, the <br />ify-tfie EHD immediately. / > <br />_______Date- 7^---------- <br />3. To be^complete^by the EN\Z 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 />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Utvvr FA# <br />Address 3/^^ Bus. Phone <br />City Zip. <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, <br />correct to the best of myjii <br />operator fails to <br />commissary owr <br />Signature'^V/-""