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Environmental Health Department <br />Date <br />Date <br />wossnso <br />FA#_____________ ____________ <br />(go?) <br />SAN JOAQUIN <br />------COUNT Y------- <br />Greatness c.- ■: <br />section 3. <br />zzu <br />Lie. Plate # Lf <br />Date <br /> <br />_2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name <br />Address ^>^7 Bus. Phone <br /> c'1 y—( __________Zip Owner/Operator ____________________ <br />Check all appropriate services provided: <br />[^astewater disposal ^^compartment sink O^iectrical hook-ups <br />E^olid,waste disposal f§?ood Preparation CMoTlet and handwashing <br />C3<^ot^& Cold water for cleaning (^/Stoi^-refrigerated food LPFotable water <br />EP^tore dry food/supplies QJ/tSvemight parking EK/ehicle wash <br />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 owner shall notify the EHD immediately. <br />Si9nature-------- Date <br /> <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co J <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 />REHS 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 <br />| 1. To be completed by APPLICANT <br />Business Name <br />Owner/Operator Name /7? QorJ i <br />Business Mailing Address <br />GityAa 14------staterAzip gS^3^us. PhJftKL ng 2 J h'cU-m Ph. <br />■ herebv state that the above information is current, true and correct to <br />e est 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 />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 1 F 209 464-0138 | www.sjgov.org/ehd