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Environmental Health Department <br />f 2- 6 -- 25 <br />j I - 2,s <br />Date <br />Lie. Plate # Z-S STU 3 <br />\PClCj ___________________ <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 lwww.sjgov.org/ehd <br />.Date <br /> <br />I 3. To be completed by the ENV HEAL TH jurisdiction outside of San Joaquin Co. <br />The commissary is located in _----- --------------------------------------------County. The above food faci|jty mee(s 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 />REHS Signature <br />SANJOMUIN <br />~ - COUNTY <br />(•;.f .... . . <br />___Co <br />kVircl <br />’ ty QW C Z i p <br />Check all appropriate services provided: <br />Wastewater disposal <br />cEKSolid waste disposal <br />(©CHot & Cold water for cleaning <br /> Store dry food/supplies <br />iDate <br /> <br />'2-To be completed by COMMISSARY OWNER/QPERATOR <br />Commissary Name C <br />Address Qt (=t <br />c Zip S <br />^^B^S-compartment sink <br /> Food preparation <br />11 Store refrigerated food <br />^Overnight parking <br />, hereby state that the information I have provided is current, true and <br />nnorotorf.il ♦ i ---------------requirements. If the food facilityoperator fads to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shah^otify the EHD immediately. <br />Signature <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ❖ Caterer <br />complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> <br />:TATobe,'cbmpletedby APPLICANT <br />Business Name £/ CWj I (A <br />Owner/Operator Name JQ5U <br />Business Mailing Address 2>Q <br /> City ------State_CHZip_5S^>_Bus. Ph.Alt. Ph. Zoci 7 57?.? <br />Signature J <br />CUy Lho FA# <br />Bus. Phone ^^70 <br />_Owner/Operator &-\Z CKp <br />4?QEIectrical hook-ups <br />A^Toilet and handwashing <br />Potable water <br />□^Vehicle wash <br />’ ———z—-------------------- - » .-----------, oiaic uiai uie II IIUI llldlion I Hi <br />correct to the best of my knowledge, and meets the California Health & Safety Code