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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 /> Vehicle wash <br />Date REHS Signature <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 | www.sjgov.org/ehd <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 />0 ^compartment sink <br />0 Food preparation <br />0 Store refrigerated food <br /> Overnight parking <br /> Electrical hook-ups <br /> Toilet and handwashing <br /> Potable water <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Business Name <br />Owner/Operator Name_ <br />Business Mailing Address , . , <br />City. <br />theo^sfa^ 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 />Date_ n/i ________ <br />3. To be completed by the ENV HEALTH jurisdictioixoutside of San Joaquin Co. <br />Bus. Phone <br />SAN JOAQUIN <br />-COUNTY- <br />Greotness grows here. <br />2. To be completed by COMMISSARY OWNER/OPERATOR____________ <br />[?p64-(F-----------____FA# Si <br />PA C _Bus. Phone_ <br />C Owner/Operator _______ <br />1. To be completec^by APPLICANT <br />by^CJULAl 7^- , ^2. cta Lie. Plate # <br />Qr_____________________ <br />AOCKhnn StatefAZip A^Z/a^us. Ph.^Q^ fcOT2.b£Z>Alt. Ph. <br />^¥TVfi^AX1fV--»4^fefedv~gtate that the above information is current, true and correct to <br />ilWFmy kno\Azj4dg"e and agree to utilize my appi <br />Commissary Name DcmU, j A <br />Add ress 3 (7 3 7~ho / <br />City S C Zip. <br />Check all appropriate services provided: <br />'j2>0'Vastewater disposal <br />^f^Solid waste disposal <br />^P^l4ot & Cold water for cleaning <br /> Store dry food/supplies <br />I, , hereby state that the information I have provided is current, true and <br />correct to the best 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 owndhsfa^ll notify the EHD immediately. <br />Sig natu re'