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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 />3. To be completed byjth <br />Date REHS Signature, <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 />P" Electrical hook-ups <br />pj Toilet and handwashing <br />iy Potable water <br />ft Vehicle wash <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />' SAN JOAQUIN <br />-COUNTY- <br />Greotness grows here. <br />1. To be completed by APPLICANT <br />Business Name LR 'Toim.n-fa L(/6'. Lie.Plate# <br />Owner/Operator Name_ <br />Business Mailing Address_ \^\ i <br />City State Cft Zip^^^O T Bus. Ph. Alt. Ph. <br />I, 53^ fa CS , 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 />Signature________ <br />2. To be completed byCQMMISSARY OWNER/OPERATOR <br />CommissaryName <br />Address Bus. Phone <br />City Zip Owner/Operator <br />Check all appropriate services provided: <br />P Wastewater disposal ft 3-compartment sink <br />ft Solid waste disposal Food preparation <br />ft Hot & Cold water for cleaning Store refrigerated food <br /> Store dry food/supplies ft Overnight parking <br />I. AJkrk __, hereby state that the information I have provided is current, true and <br />correct to the best of my kqawledg'e, 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 shaH notify the EHD immediately. <br />S i g n a t u re <br />NV HEALTH jurisdiction outside of San Joaquin Co. <br />FA#