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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 />Date <br />Date <br />Date REHS Signature <br />ET Electrical hook-ups <br />T3 Toilet and handwashing <br />Potable water <br />S 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 />1. To be completed by APPLICANT___ <br />SAN JOAQUIN <br />----COUNTY------ <br />Gregfneis orows here. <br />-------<r •__________________________ __ <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 />Lie. Plate #_ <br />>up pl ___F A#____________ <br />Bus. Phone 7 O <br />t2f 3-compartment sink <br />& Food preparation <br />S' Store refrigerated food <br />$3 Overnight parking <br />04 \ i O_________, hereby state that the information I have provided i <br />e oest of my knowledge, and meets the California Health & Safety Code requirements <br />Business Name_ X/tU rwHnQj___ <br />0wner/Operator Name \X/\(AVA.________ <br />Business Mailing Address_ nJ <br />City StateCA ZipHS'Z.^^ Bus. Ph. 05"-^^Alt. Ph. <br />i. /Ink T-._ 7) Iv&virH , 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 />S i g n a t u r e _ ------ <br />2. To be completed by COMMISSARY OWNER/QPERATOR <br />Commissary NameAHjrniu. TCfinj <br />Address Z 5> Ly/r^ <br />City H-kycK-ivy/i Zip A Qwner/Operator <br />Check all appropriate services provided: <br />|3 Wastewater disposal <br />H Solid waste disposal <br />Hot & Cold water for cleaning <br />Ej Store dry food/supplies <br />I, S i O , hereby state that the information I have provided is current, true and <br />correct to the oest 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 immediately. > > <br />Signature o ___'JDate 7 / -----------------------