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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 />Date4-u <br />Date RtHS Signature <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />Lie. Plate# <br />Bi Electrical hook-ups <br />Toilet and handwashing <br />Dotable water <br />A Oczi M B 7.COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SANJOAOUIN <br />------COUNTY------- <br />Greatness grows here. <br />C Ci o( a, <br />I <br />1. To be completed by APPLICANT_______ <br />Bus. Ph.(sio)H0-goT-i <br />QlfWastewater disposal <br />[ti^Solid waste disposal <br /> Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I, <br />correct to the best of my knowledge, and giei <br />Business Name <br />Owner/Operator Name i\ <br />Business Mailing Address <br />City state Zip Bus. Ph.(sio)H0-goT-i Alt. Ph/^QJ'?.? -32^ <br />I, , 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 Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR________________ <br />Commissary Name fa# <br />Address_ /(p J-O/ Rj.____Bus. Phone <2.0? - 7/2-- 76 <br />City. zip pr33z> Owner/Operator <br />Check all appropriate services provided: <br />La d-compartment sink <br />k ’ Food preparation <br /> Store refrigerated food <br />B^Overnight parking Vehicle wash <br />I , hereby state that the information I have provided is current, true and <br />correct to the best of my knowledge, and /eets 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-EJHD immediately. . . <br />S i g n at u re ---< fjLu— —7^Da te J/S ___________ <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.